HESI MILESTONE 2 ACTUAL EXAM 3
LATEST VERSIONS (V1, V2 AND V3)
EACH VERSION CONTAINS 200+
QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
/. 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 left-sided 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."
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."
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 with heart failure has been experiencing difficulty with completion of daily
activities, as evidenced by exertional fatigue and increased blood pressure. Which
observation by the nurse best indicates client progress in meeting goals for this
problem?
1. Ambulates 10 feet (3 meters) farther each day
2. Verbalizes the benefits of increasing activity
3. Chooses a healthy diet that meets caloric needs
4. Sleeps without awakening throughout the night - Answer-✅Chooses a healthy diet
that meets caloric needs
, Each of the options indicates a positive outcome on the part of the client. Both option 2
and the correct one relate to the client problem of difficulty with completion of daily
activities. However, the question asks about progress. The correct option is more
action-oriented and therefore is the better choice. Option 3 would most likely indicate
progress if the client had a problem of inadequate nutritional intake. Option 4 would be a
satisfactory outcome for a client experiencing difficulty sleeping.
/.A client with coronary artery disease is scheduled to have a diagnostic exercise stress
test. Which instruction would the nurse plan to provide to the client about this
procedure?
1. Eat breakfast just before the procedure.
2. Wear firm, rigid shoes, such as work boots.
3. Wear loose clothing with a shirt that buttons in front.
4. Avoid cigarettes for 30 minutes before the procedure. - Answer-✅Wear loose
clothing with a shirt that buttons in front.
The client needs to wear loose, comfortable clothing for the procedure.
Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that
buttons in the front. The client needs to receive nothing by mouth after bedtime or for a
minimum of 2 hours before the test. The client would wear rubber-soled, supportive
shoes, such as athletic training shoes. The client needs to avoid smoking, alcohol, and
caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the
test, with the potential for a false-positive result.
/.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?
LATEST VERSIONS (V1, V2 AND V3)
EACH VERSION CONTAINS 200+
QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
/. 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 left-sided 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."
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."
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 with heart failure has been experiencing difficulty with completion of daily
activities, as evidenced by exertional fatigue and increased blood pressure. Which
observation by the nurse best indicates client progress in meeting goals for this
problem?
1. Ambulates 10 feet (3 meters) farther each day
2. Verbalizes the benefits of increasing activity
3. Chooses a healthy diet that meets caloric needs
4. Sleeps without awakening throughout the night - Answer-✅Chooses a healthy diet
that meets caloric needs
, Each of the options indicates a positive outcome on the part of the client. Both option 2
and the correct one relate to the client problem of difficulty with completion of daily
activities. However, the question asks about progress. The correct option is more
action-oriented and therefore is the better choice. Option 3 would most likely indicate
progress if the client had a problem of inadequate nutritional intake. Option 4 would be a
satisfactory outcome for a client experiencing difficulty sleeping.
/.A client with coronary artery disease is scheduled to have a diagnostic exercise stress
test. Which instruction would the nurse plan to provide to the client about this
procedure?
1. Eat breakfast just before the procedure.
2. Wear firm, rigid shoes, such as work boots.
3. Wear loose clothing with a shirt that buttons in front.
4. Avoid cigarettes for 30 minutes before the procedure. - Answer-✅Wear loose
clothing with a shirt that buttons in front.
The client needs to wear loose, comfortable clothing for the procedure.
Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that
buttons in the front. The client needs to receive nothing by mouth after bedtime or for a
minimum of 2 hours before the test. The client would wear rubber-soled, supportive
shoes, such as athletic training shoes. The client needs to avoid smoking, alcohol, and
caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the
test, with the potential for a false-positive result.
/.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?
