HESI MILESTONE 2 ACTUAL EXAM 3 LATEST VERSIONS (V1, V2 AND V3) EACH VERSION CONTAINS 100 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
HESI MILESTONE 2 ACTUAL EXAM 3
LATEST VERSIONS (V1, V2 AND V3) EACH
VERSION CONTAINS 100 QUESTIONS AND
CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY
GRADED A+
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?
- Restricting fluids
- Placing a pillow under the knees
- Encouraging active range-of-motion exercises
- Applying a heating pad to the lower extremities – ….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
compression. Keeping the client well hydrated is essential because dehydration
predisposes to clotting. A pillow under the knees may cause venous stasis. Heat
would not be applied without a primary health care provider’s prescription.
The nurse is caring for a teenage client admitted to the hospital with a suspected
diagnosis of acute appendicitis. Which laboratory result should the nurse expect to
note if the client does have appendicitis? - Leukopenia with a shift to the left
- Leukocytosis with a shift to the left
- Leukopenia with a shift to the right
- Leukocytosis with a shift to the right – ….ANSWER…Leukocytosis with a shift to
the left
RATIONALE: Laboratory findings do not establish the diagnosis of appendicitis, but
there is often an elevation of the white blood cell count (leukocytosis) with a shift to
the left (an increased number of immature white blood cells). Options 1, 3, and 4 are
incorrect because they are not associated findings in acute appendicitis.
A home care nurse is visiting a client to provide follow-up evaluation and care of a
leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer
is pale and deep and that the surrounding tissue is cool to the touch. The nurse
would document that these findings identify which type of ulcer?
- A stage 1 ulcer
- A vascular ulcer
- An arterial ulcer
- A venous stasis ulcer – ….ANSWER…An arterial ulcer
RATIONALE: Arterial ulcers have a pale deep base and are surrounded by tissue
that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are
caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A
stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis
ulcer (vascular) has a dark red base and is surrounded by brown skin with local
edema. This type of ulcer is caused by the accumulation of waste products of
metabolism that are not cleared, as a result of venous congestion.
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? - “Apply warm packs to the leg.”
- “Keep the leg elevated as much as possible.”
- “Your primary health care provider needs to be contacted to report this problem.”
- “This normally occurs after surgery and will subside when the edema goes down.”
- ….ANSWER…”Your primary health care provider needs to be contacted to report
this problem.”
RATIONALE: 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.
The nurse has completed an educational course about first-degree heart block.
Which statement by the nurse indicates that teaching has been effective?
- “Presence of Q waves indicates first-degree heart block.”
- “Tall, peaked T waves indicate first-degree heart block.”
- “Widened QRS complexes indicate first-degree heart block.”
- “Prolonged, equal PR intervals indicate first-degree heart block.” –
….ANSWER…”Prolonged, equal PR intervals indicate first-degree heart block.”
RATIONALE: Prolonged and equal PR intervals indicate first-degree heart block.
The development of Q waves indicates myocardial necrosis. Tall, peaked T waves
may indicate hyperkalemia. A widened QRS complex indicates a delay in
intraventricular conduction, such as bundle branch block. An electrocardiogram
(ECG) taken during a pain episode is intended to capture ischemic changes, which
also include ST segment elevation or depression.
The ambulatory care nurse is working with a client who has been diagnosed with
Prinzmetal’s (variant) angina. What would the nurse plan to teach the client about
this type of angina?
- It is most effectively managed by beta-blocking agents.
- It has the same risk factors as stable and unstable angina.
- It can be controlled with a low-sodium, high-potassium diet.
- Generally it is treated with calcium channel-blocking agents. –
….ANSWER…Generally it is treated with calcium channel-blocking agents.
RATIONALE: Prinzmetal’s angina results from spasm of the coronary vessels and is
treated with calcium channel blockers. Beta blockers are contraindicated because
they may actually worsen the spasm. The risk factors are unknown, and this type of
angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated.
A client with myocardial infarction (MI) has been transferred from the coronary care
unit (CCU) to the general medical unit. What activity level would the nurse
encourage for the client immediately after transfer? - Ad lib activities as tolerated
- Strict bed rest for 24 hours after transfer
- Bathroom privileges and self-care activities
- Unsupervised hallway ambulation for distances up to 200 feet (60 meters) –
….ANSWER…Bathroom privileges and self-care activities
RATIONALE: On transfer from CCU to an intermediate care or general medical unit,
the client is allowed self-care activities and bathroom privileges. Activities ad lib as
tolerated is premature at this time and potentially harmful for this client. It is
unnecessary and possibly harmful to limit the client to bed rest. The client would
ambulate with supervision in the hall for brief distances, with the distances being
gradually increased to 50, 100, and 200 feet (15, 30, and 60 meters).
A client with no history of heart disease has experienced acute myocardial infarction
and has been given thrombolytic therapy with tissue plasminogen activator. What
assessment finding would the nurse identify as an indicator that the client is
experiencing complications of this therapy? - Tarry stools
- Nausea and vomiting
- Orange-colored urine
- Decreased urine output – ….ANSWER…Tarry stools
Thrombolytic agents are used to dissolve existing thrombi, and the nurse would
monitor the client for obvious or occult signs of bleeding. This includes assessment
for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It
also includes Hematest testing of secretions for occult blood. The correct option is
the only one that indicates the presence of blood.
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?
- Ronchi
- Wheezes
- Crackles in the bases
- Crackles throughout the lung fields – ….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 hospitalized client has been diagnosed with heart failure as a complication of
hypertension. In explaining the disease process to the client, the nurse identifies
which chamber of the heart as primarily responsible for the symptoms? - Left atrium
- Right atrium
- Left ventricle
- Right ventricle – ….ANSWER…Left ventricle
Hypertension increases the workload of the left ventricle because the ventricle has to
pump the stroke volume against increased resistance (afterload) in the major blood
vessels. Over time this causes the left ventricle to fail, leading to signs and
symptoms of heart failure. The remaining options are not the chambers that are
primarily responsible for this disease process, although these chambers may be
affected as the disease becomes more chronic.
The registered nurse (RN) is educating a new nurse on mitral stenosis. Which
statement by the new nurse indicates that the teaching has been effective? - “Left ventricle to aorta narrowing will impede flow of blood.”
- “Left atrium to left ventricle narrowing will impede flow of blood.”
- “Right atrium to right ventricle narrowing will impede flow of blood.”
- “Right ventricle to pulmonary artery narrowing will impede flow of blood.” –
….ANSWER…”Left atrium to left ventricle narrowing will impede flow of blood.”
The mitral valve separates the left atrium from the left ventricle. The remaining
options describe impeded flow due to aortic, tricuspid, and pulmonic stenosis,
respectively.
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