HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS (V1, V2 AND V3) 2023-2024
EACH VERSION CONTAINS 100 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+ 2025/2026
. -Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
24 hour- Jaundice - ANSPhysiologic jaundice occurs from a normal reduction in red blood cells. Pathologic
jaundice occurs within first 24 hours of life OR persists beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is
discharged. What nursing intervention is appropriate in addressing this behavior? - ANSDiscuss activities
that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team,
and if the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to
implement which nursing task appropriate for this phase? - ANSMaking appropriate referrals
ABG findings - ANSpH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSHistory, ETOH abuse, severe LUQ pain, tachy, restless, decrease bowel,
jaundice, grey turner or Cullen signs, increase serum amylase/lipase or WBC, hyperlipidemia
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
,o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANS- weakness
,- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ANS- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANS5-phase cycle= Triggering (event), Escalation (movement toward a loss of control),
Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Alcohol withdrawal - ANS- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
, - Tremors, nausea, vomiting
Alcoholic hepatis teaching - ANS- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSRestless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANS- mostly men
- legs mostly affected
arterial insufficiency symptoms - ANS-weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
Asthma Triggers: - ANSDust, mites, roaches, cloth, pets, horses, detergents, soaps, food, mold, pollens, seasonal
Bizarre social behavior - ANS- assess physical needs, suicide risk, ensure safety at all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Boggy Uterus Actions - ANS- massage and administer uterotonic to increase uterine contraction.
- give oxytocin
Cancer intractable pain plan of care - ANSo Pain, other symptoms and side effects are managed based on the
best available evidence, with attention to disease-specific pain and symptoms, which are skillfully and
systematically applied. ??????
Cardiomyopathy care plan - ANS○ Medications- digoxin, diuretics, antidysrhythmic, antihypertensive
medications
EACH VERSION CONTAINS 100 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+ 2025/2026
. -Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
24 hour- Jaundice - ANSPhysiologic jaundice occurs from a normal reduction in red blood cells. Pathologic
jaundice occurs within first 24 hours of life OR persists beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is
discharged. What nursing intervention is appropriate in addressing this behavior? - ANSDiscuss activities
that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team,
and if the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to
implement which nursing task appropriate for this phase? - ANSMaking appropriate referrals
ABG findings - ANSpH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSHistory, ETOH abuse, severe LUQ pain, tachy, restless, decrease bowel,
jaundice, grey turner or Cullen signs, increase serum amylase/lipase or WBC, hyperlipidemia
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
,o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANS- weakness
,- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ANS- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANS5-phase cycle= Triggering (event), Escalation (movement toward a loss of control),
Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Alcohol withdrawal - ANS- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
, - Tremors, nausea, vomiting
Alcoholic hepatis teaching - ANS- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSRestless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANS- mostly men
- legs mostly affected
arterial insufficiency symptoms - ANS-weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
Asthma Triggers: - ANSDust, mites, roaches, cloth, pets, horses, detergents, soaps, food, mold, pollens, seasonal
Bizarre social behavior - ANS- assess physical needs, suicide risk, ensure safety at all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Boggy Uterus Actions - ANS- massage and administer uterotonic to increase uterine contraction.
- give oxytocin
Cancer intractable pain plan of care - ANSo Pain, other symptoms and side effects are managed based on the
best available evidence, with attention to disease-specific pain and symptoms, which are skillfully and
systematically applied. ??????
Cardiomyopathy care plan - ANS○ Medications- digoxin, diuretics, antidysrhythmic, antihypertensive
medications
