HESI MILESTONE 2 EXAM | QUESTIONS
AND VERIFIED ANSWERS WITH
RATIONALE RATED A+ | 2024/2025
GUIDE
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.
- Correct Answer - Weigh self on a daily basis.
Rationale: 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?
1. Inability to pass flatus
2. Loss of anal sphincter control
3. Severe, constant pain with rapid onset
4. Firm, nontender mass palpable at the lower right costal margin
- Correct Answer - Inability to pass flatus
Rationale: An inflammatory reaction such as acute pancreatitis
can cause paralytic ileus, the most common form of
nonmechanical obstruction. Inability to pass flatus is a clinical
manifestation of paralytic ileus. Loss of sphincter control is not a
sign of paralytic ileus. Pain is associated with paralytic ileus, but
the pain usually manifests as a more constant generalized
discomfort. Option 4 is the description of the physical finding of
liver enlargement. The liver may be enlarged in cases of cirrhosis
or hepatitis. Although this client may have an enlarged liver, an
,enlarged liver is not a sign of paralytic ileus or intestinal
obstruction.
The nurse is caring for a client with a resolved intestinal
obstruction who has a nasogastric tube in place. The primary
health care provider has now prescribed that the nasogastric tube
be removed. What is the priority nursing assessment prior to
removing the tube?
1. Checking for normal serum electrolyte levels
2. Checking for normal pH of the gastric aspirate
3. Checking for proper nasogastric tube placement
4. Checking for the presence of bowel sounds in all four
quadrants
- Correct Answer - Checking for the presence of bowel sounds
in all four quadrants
Rationale: Distention, vomiting, and abdominal pain are a few of
the symptoms associated with intestinal obstruction. Nasogastric
tubes may be used to remove gas and fluid from the stomach,
relieving distention and vomiting. Bowel sounds return to normal
as the obstruction is resolved and normal bowel function is
restored. Discontinuing the nasogastric tube before normal bowel
, function may result in a return of the symptoms, necessitating
reinsertion of the nasogastric tube. Serum electrolyte levels, pH of
the gastric aspirate, and tube placement are important
assessments for the client with a nasogastric tube in place but
would not assist in determining the readiness for removing the
nasogastric tube.
The nurse is caring for a client who is on strict bed rest and
creates a plan of care with goals related to the prevention of deep
vein thrombosis and pulmonary emboli. Which nursing action is
most helpful in preventing these disorders from developing?
1. Restricting fluids
2. Placing a pillow under the knees
3. Encouraging active range-of-motion exercises
4. Applying a heating pad to the lower extremities
- Correct Answer - Encouraging active range-of-motion
exercises
Rationale: Clients at greatest risk for deep vein thrombosis and
pulmonary emboli are immobilized clients. Basic preventive
measures include early ambulation, leg elevation, active leg
exercises, elastic stockings, and intermittent pneumatic calf
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