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) 2023-2024 EACH VERSION CONTAINS 100

QUESTIONS AND CORRECT DETAILED ANSWERS

(VERIFIED ANSWERS) |ALREADY GRADED A+

VERSION 1

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 - 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?

1. Leukopenia with a shift to the left

2. Leukocytosis with a shift to the left

3. Leukopenia with a shift to the right

4. 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?

1. A stage 1 ulcer

2. A vascular ulcer

3. An arterial ulcer

4. 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?

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." - 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?

1. "Presence of Q waves indicates first-degree heart block."

2. "Tall, peaked T waves indicate first-degree heart block."

3. "Widened QRS complexes indicate first-degree heart block."

4. "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?

1. It is most effectively managed by beta-blocking agents.

2. It has the same risk factors as stable and unstable angina.

3. It can be controlled with a low-sodium, high-potassium diet.

4. Generally it is treated with calcium channel-blocking agents. - ANSWERGenerally 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?

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