HESI Milestone 2 Fall 2024 Questions With Complete
Solutions
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." Correct 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.
,A client had a colectomy 2 days earlier to remove a bowel tumor
and had a new colostomy created. The client is beginning to pass
malodorous flatus from the stoma. What is the correct
interpretation by the nurse?
1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client would not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel preparation.
Correct Answer This is a normal, expected event.
As peristalsis returns following creation of a colostomy, the
client begins to pass malodorous flatus. This indicates returning
bowel function and is an expected event. Within 72 hours of
surgery, the client would begin passing stool via the colostomy.
Options 2, 3, and 4 are incorrect interpretations.
A client has been prescribed clozapine. The nurse reviews the
result of which laboratory study to detect a serious adverse
effect associated with this medication?
1. Platelet count
2. Liver function
3. Blood glucose level
4. White blood cell count Correct Answer Platelet count
Clozapine is an antipsychotic medication. The client taking
clozapine may experience agranulocytosis as an adverse effect,
which is monitored by obtaining weekly white blood cell counts.
Treatment is withheld if the level drops below 3000 mm3 (3 ×
, 109/L). Agranulocytosis could be fatal if undetected and
untreated. The other options are incorrect.
A client has experienced an episode of pulmonary edema. The
nurse determines that the client's respiratory status is improving
after this episode if which breath sounds are noted?
1. Ronchi
2. Wheezes
3. Crackles in the bases
4. Crackles throughout the lung fields Correct Answer Crackles
in the base
Pulmonary edema is characterized by extreme breathlessness,
dyspnea, air hunger, and the production of frothy, pink-tinged
sputum. As the client's condition improves, the amount of fluid
in the alveoli decreases, which may be detected by crackles in
the bases. (Clear lung sounds indicate full resolution of the
episode.) Rhonchi and wheezes are not associated with
pulmonary edema. Auscultation of the lungs reveals crackles
throughout the lung fields.
A client received 20 units of Humulin N insulin subcutaneously
at 08:00. At what time would the nurse plan to assess the client
for a hypoglycemic reaction?
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