HESI MILESTONE #2 LATEST 2023-2024 145 QUESTIONS
AND VERIFIED ANSWERS WITH RATIONALES |A+ GRADED|
SAUNDERS MEDSURG CARDIOVASCULAR
1. A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled
for cardiac catheterization. Which medication would need to be withheld for 24 hours before the
procedure and for 48 hours after the procedure?
• Glipizide
• Metformin
• Repaglinide
• Regular insulin
Answer:
2. Metformin
Rationale:
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because
of the injection of contrast medium during the procedure. If the contrast medium affects kidney
function, with metformin in the system the client would be at increased risk for lactic acidosis. The
medications in the remaining options do not need to be withheld 24 hours before and 48 hours after
cardiac catheterization.
3. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are
regular.The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart
rate is 64 beats/minute. Which action should the nurse take?
1. Check vital signs.
2. Check laboratory test results.
3. Notify the health care provider.
4. Continue to monitor for any rhythm change.
Answer:
4. Continue to monitor for any rhythm change.
Rationale:
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The
PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10
seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need
to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse
would continue to monitor the client for any rhythm change.
,4. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no
electrocardiographic complexes on the screen. Which is the priority nursing action?
• Call a code.
• Call the health care provider.
• Check the client's status and lead placement.
• Press the recorder button on the electrocardiogram console.
Answer:
3. Check the client's status and lead placement.
Rationale:
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode
displacement. Accurate assessment of the client and equipment is necessary to determine the cause and
identify the appropriate intervention. The remaining options are secondary to client assessment.
7. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR
interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are
regular. How should the nurse correctly interpret this rhythm?
• Sinus tachycardia
• Sinus bradycardia
• Sinus dysrhythmia
• Normal sinus rhythm
Answer:
1. Sinus tachycardia
Rationale:
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and
normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia,
the atrial and ventricular rates are greater than 100 beats/minute.
8. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4
hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness
and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly
interpret the client's neurovascular status?
• The neurovascular status is normal because of increased blood flow through the leg.
• The neurovascular status is moderately impaired, and the surgeon should be called.
• The neurovascular status is slightly deteriorating and should be monitored for another
hour.
• The neurovascular status is adequate from an arterial approach, but venous
complications are arising.
,Answer:
1. The neurovascular status is normal because of increased blood flow through the leg.
Rationale:
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical
extremity because of increased blood flow. The remaining options are incorrect interpretations.
12. The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about
home care management and self-care management. Which statement, if made by the client, indicates a
need for further instruction?
• "I need to be sure not to go barefoot around the house."
• "If I cut my toenails, I need to be sure that I cut them straight across."
• "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."
• "I need to be sure that I elevate my leg above the level of my heart for at least an hour
every day."
Answer:
4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."
Rationale:
Foot care instructions for the client with peripheral arterial disease are the same as those for a client
with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the
level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also
present. The client statements in the remaining options are correct statements, and indicate that the
teaching has been effective.
13. The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium
items to be avoided. The nurse instructs the client to avoid consuming which item?
• Bananas
• Broccoli
• Antacids
• Cantaloupe
Answer:
3. Antacids
Rationale:
The sodium level can increase with the use of several types of products, including toothpaste and
mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and
softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is
, bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and
vegetables are low in sodium.
14. The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should
plan to provide which instruction to the client?
• Use nail polish to protect the nail beds from injury.
• Wear gloves for all activities involving the use of both hands.
• Stop smoking because it causes cutaneous blood vessel spasm.
• Always wear warm clothing, even in warm climates, to prevent vasoconstriction
Answer:
3. Stop smoking because it causes cutaneous blood vessel spasm.
Rationale:
Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the
extremities. Smoking cessation is one of the most important lifestyle changes that the client must make.
The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in
stopping smoking. The nurse needs to provide information to the client about smoking cessation
programs available in the community. It is not necessary to wear gloves for all activities, nor should
warm clothing be worn in warm climates.
15. The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown
occurred over the varicosities as a result of secondary infection. Which is a priority intervention?
• Keep the legs aligned with the heart.
• Elevate the legs higher than the heart.
• Clean the skin with alcohol every hour.
• Position the client onto the side during every shift.
Answer:
2. Elevate the legs higher than the heart.
Rationale:
In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the
return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be
used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority
intervention.
16. The nurse in the medical unit is reviewing the laboratory test results for a client who has been
transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was
performed while the client was in the ICU. The nurse determines that this test was performed to assist in
diagnosing which condition?
• Heart failure
• Atrial fibrillation
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