HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS
2023-2024 EACH VERSION CONTAINS 140+ QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
1. A client admitted to the hospital with chest pain and a history of type 2
diabetes mellitus is scheduled for cardiac catheterization. Which medication
would need to be withheld for 24 hours before the procedure and for 48 hours
after the procedure?
• Glipizide
• Metformin
• Repaglinide
• Regular insulin
Answer:
2. Metformin
Rationale:
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac
catheterization because of the injection of contrast medium during the
procedure. If the contrast medium affects kidney function, with metformin in the
system the client would be at increased risk for lactic acidosis. The
medications in the remaining options do not need to be withheld 24 hours before
and 48 hours after cardiac catheterization.
3. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS
complexes are
regular.The PR interval is 0.16 seconds, and QRS complexes measure 0.06
seconds. The overall heart rate is 64 beats/minute. Which action should the
nurse take?
1. Check vital signs.
2. Check laboratory test results.
3. Notify the health care provider.
4. Continue to monitor for any rhythm change.
5.
,Answer:
4. Continue to monitor for any rhythm change.
Rationale:
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to
100 beats/minute. The PR and QRS measurements are normal, measuring
between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There
are no irregularities in this rhythm currently, so there is no immediate need to
check vital signs or laboratory results, or to notify the health care provider.
Therefore, the nurse
would continue to monitor the client for any rhythm change.
4. A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which
is the priority nursing action?
• Call a code.
• Call the health care provider.
• Check the client's status and lead placement.
• Press the recorder button on the electrocardiogram console.
Answer:
3. Check the client's status and lead placement.
Rationale:
Sudden loss of electrocardiographic complexes indicates ventricular asystole or
possibly electrode displacement. Accurate assessment of the client and
equipment is necessary to determine the cause and identify the appropriate
intervention. The remaining options are secondary to client assessment.
7. Aclient's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures
0.08 seconds, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
• Sinus tachycardia
• Sinus bradycardia
• Sinus dysrhythmia
• Normal sinus rhythm
,Answer:
1. Sinus tachycardia
Rationale:
Sinus tachycardia has the characteristics of normal sinus rhythm, including a
regular PP interval and normal-width PR and QRS intervals; however, the rate is
the differentiating factor. In sinus tachycardia, the atrial and ventricular rates
are greater than 100 beats/minute.
8. The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. How should the nurse correctly
interpret the client's neurovascular status?
• The neurovascular status is normal because of increased blood flow through
the leg.
• The neurovascular status is moderately impaired, and the surgeon should be
called.
• The neurovascular status is slightly deteriorating and should be
monitored for another hour.
• The neurovascular status is adequate from an arterial
approach, but venous complications are arising.
Answer:
1. The neurovascular status is normal because of increased blood flow through the leg.
Rationale:
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and
edema in the surgical extremity because of increased blood flow. The remaining
options are incorrect interpretations.
12. The home care nurse is providing instructions to a client with an arterial
ischemic leg ulcer about home care management and self-care management.
Which statement, if made by the client, indicates a need for further instruction?
• "I need to be sure not to go barefoot around the house."
• "If I cut my toenails, I need to be sure that I cut them straight across."
, • "It is all right to apply lanolin to my feet, but I shouldn't place it between my
toes."
• "I need to be sure that I elevate my leg above the level of my heart
for at least an hour every day."
Answer:
4. "I need to be sure that I elevate my leg above the level of my heart for at least an
hour every day."
Rationale:
Foot care instructions for the client with peripheral arterial disease are the same as those
for a client
with diabetes mellitus. The client with arterial disease, however, should avoid
raising the legs above the level of the heart unless instructed to do so as part of an
exercise program or if venous stasis is also
present. The client statements in the remaining options are correct statements,
and indicate that the teaching has been effective.
13. The nurse is providing instructions to a client with a diagnosis of hypertension
regarding high-sodium items to be avoided. The nurse instructs the client to avoid
consuming which item?
• Bananas
• Broccoli
• Antacids
• Cantaloupe
Answer:
3. Antacids
Rationale:
The sodium level can increase with the use of several types of products, including
toothpaste and mouthwash; over-the-counter medications such as analgesics,
antacids, laxatives, and sedatives; and softened water and mineral water. Clients
are instructed to read labels for sodium content. Water that is
2023-2024 EACH VERSION CONTAINS 140+ QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
1. A client admitted to the hospital with chest pain and a history of type 2
diabetes mellitus is scheduled for cardiac catheterization. Which medication
would need to be withheld for 24 hours before the procedure and for 48 hours
after the procedure?
• Glipizide
• Metformin
• Repaglinide
• Regular insulin
Answer:
2. Metformin
Rationale:
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac
catheterization because of the injection of contrast medium during the
procedure. If the contrast medium affects kidney function, with metformin in the
system the client would be at increased risk for lactic acidosis. The
medications in the remaining options do not need to be withheld 24 hours before
and 48 hours after cardiac catheterization.
3. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS
complexes are
regular.The PR interval is 0.16 seconds, and QRS complexes measure 0.06
seconds. The overall heart rate is 64 beats/minute. Which action should the
nurse take?
1. Check vital signs.
2. Check laboratory test results.
3. Notify the health care provider.
4. Continue to monitor for any rhythm change.
5.
,Answer:
4. Continue to monitor for any rhythm change.
Rationale:
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to
100 beats/minute. The PR and QRS measurements are normal, measuring
between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There
are no irregularities in this rhythm currently, so there is no immediate need to
check vital signs or laboratory results, or to notify the health care provider.
Therefore, the nurse
would continue to monitor the client for any rhythm change.
4. A client is wearing a continuous cardiac monitor, which begins to sound its
alarm. The nurse sees no electrocardiographic complexes on the screen. Which
is the priority nursing action?
• Call a code.
• Call the health care provider.
• Check the client's status and lead placement.
• Press the recorder button on the electrocardiogram console.
Answer:
3. Check the client's status and lead placement.
Rationale:
Sudden loss of electrocardiographic complexes indicates ventricular asystole or
possibly electrode displacement. Accurate assessment of the client and
equipment is necessary to determine the cause and identify the appropriate
intervention. The remaining options are secondary to client assessment.
7. Aclient's electrocardiogram strip shows atrial and ventricular rates of 110
beats/minute. The PR interval is 0.14 seconds, the QRS complex measures
0.08 seconds, and the PP and RR intervals are regular. How should the nurse
correctly interpret this rhythm?
• Sinus tachycardia
• Sinus bradycardia
• Sinus dysrhythmia
• Normal sinus rhythm
,Answer:
1. Sinus tachycardia
Rationale:
Sinus tachycardia has the characteristics of normal sinus rhythm, including a
regular PP interval and normal-width PR and QRS intervals; however, the rate is
the differentiating factor. In sinus tachycardia, the atrial and ventricular rates
are greater than 100 beats/minute.
8. The nurse is assessing the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. How should the nurse correctly
interpret the client's neurovascular status?
• The neurovascular status is normal because of increased blood flow through
the leg.
• The neurovascular status is moderately impaired, and the surgeon should be
called.
• The neurovascular status is slightly deteriorating and should be
monitored for another hour.
• The neurovascular status is adequate from an arterial
approach, but venous complications are arising.
Answer:
1. The neurovascular status is normal because of increased blood flow through the leg.
Rationale:
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and
edema in the surgical extremity because of increased blood flow. The remaining
options are incorrect interpretations.
12. The home care nurse is providing instructions to a client with an arterial
ischemic leg ulcer about home care management and self-care management.
Which statement, if made by the client, indicates a need for further instruction?
• "I need to be sure not to go barefoot around the house."
• "If I cut my toenails, I need to be sure that I cut them straight across."
, • "It is all right to apply lanolin to my feet, but I shouldn't place it between my
toes."
• "I need to be sure that I elevate my leg above the level of my heart
for at least an hour every day."
Answer:
4. "I need to be sure that I elevate my leg above the level of my heart for at least an
hour every day."
Rationale:
Foot care instructions for the client with peripheral arterial disease are the same as those
for a client
with diabetes mellitus. The client with arterial disease, however, should avoid
raising the legs above the level of the heart unless instructed to do so as part of an
exercise program or if venous stasis is also
present. The client statements in the remaining options are correct statements,
and indicate that the teaching has been effective.
13. The nurse is providing instructions to a client with a diagnosis of hypertension
regarding high-sodium items to be avoided. The nurse instructs the client to avoid
consuming which item?
• Bananas
• Broccoli
• Antacids
• Cantaloupe
Answer:
3. Antacids
Rationale:
The sodium level can increase with the use of several types of products, including
toothpaste and mouthwash; over-the-counter medications such as analgesics,
antacids, laxatives, and sedatives; and softened water and mineral water. Clients
are instructed to read labels for sodium content. Water that is
