Hesi Milestone 2 Exam Practice Version 1 (2023/ 2024) | 160 Questions and Verified Answers with Rationales| 100% Correct
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Hesi Milestone 2
Hesi Milestone 2 Exam Practice Version 1 (2023/ 2024) | 160 Questions and Verified Answers| 100% Correct
Q: A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate?
A. Bilateral lower leg stasis dermatitis. B. Clubbing of fingers and toes.
C. I...
Hesi Milestone 2 Exam Practice Version 1 (2023/ 2024) | 1 60 Questions and Verified Answers| 100% Correct Q: A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? A. Bilateral lower leg stasis dermatitis. B. Clubbing of fingers and toes. C. Intermittent claudication. D. Peripheral cyanosis. Answer: C Clients who suffer from chronic venous insufficiency often develop stasis dermatitis in the lower extremities. Stasis dermatitis appear as brownish -red discoloration on the lower extremities at the ankles which can develop into stasis ulcers due to the pooling of the venous blood flow back to the heart. Q: Which statement made by a client with chronic pancreatitis indicates that further education is needed? A. I will cut back on smoking cigarettes daily. B. I will avoid drinking caffeinated beverages. C. I will res t frequently and avoid vigorous exercise. D. I will eat a bland, low -fat, high -protein diet. Answer: A To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinat ed beverages, resting frequently as needed, and eating a bland diet low fat and high in protein. Q: A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statem ent by the client conveys an understanding of the etiology of divertic - ula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Divertic ulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out -pouching sacs. Answer: D A client who has chronic constipation often strains to pass constipated stool which incr eases intestinal pressure that weakens the intestinal walls and causes out -pouching sacs, called diverticula which commonly occur in the sigmoid. Q: Small bowel obstruction is a condition characterized by which finding? A. Severe fluid and electrolyte imba lances. B. Metabolic acidosis. C. Ribbon -like stools. D. Intermittent lower abdominal cramping. Answer: A Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances. Q: The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor Answer: A When assessing a client with chronic kidn ey disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority. Q: The nurse is planning care for a client with newly dia gnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Present knowledge related to the skill of injection. B. Intelligence and developmental level of the client. C. Willingness of the client to learn the injection sites. D. Financial resources available for the equipment. Answer: C If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching. Q: A client with gastroesophageal reflux disease (GERD) has been experienc - ing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A. Losing weight. B. Decreasing caffeine intake C. Avoiding large meals. D. Raising the head of the bed on blocks. Answer: D Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non -pharmacological e ffective recom - mendation for a client experiencing severe gastroesophageal reflux during sleep. Q: The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? A. Place a chair at a right angle to th e bedside. B. Encourage deep breathing prior to standing. C. Help the client to sit and dangle legs on the side of the bed. D. Allow the client to sit with the bed in a high Fowler's position. Answer: D The first step in assisting a client out of bed for th e first time after surgery is to raise the head of the bed to a high Fowler's position, which allows venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light -headed a nd decreases the chance of a client fall. Q: After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post -anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? A. Report the findings to the surgeon. B. Irrigate the indwelling urinary catheter. C. Apply manual pressure to the bladder. D. Increase the IV flow rate for 15 minutes. Answer: A After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. Q: The nurse formulates the nursing problem of urinary retention relate d to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? A. Teach the client techniques of intermittent self -catheterization. B. Decrease fluid intake to prevent over distention of the bladder. C. Use incontinence briefs to maintain hygiene with urinary dribbling. D. Explain that anticholinergic drugs will decrease muscle spasticity. Answer: A Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self -catheterization to prevent bladder distention. Q: A client with a 16 -year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and se rum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Dyspnea. B. Nocturia. C. Confusion. D. Stomatitis. Answer: B As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes, accumulate in the blood. In the early stage of renal insuffic iency, polyuria results from the inability of the kidneys to concentrate urine and contributes to nocturia.
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