HESI MILESTONE 2 EXAM | QUESTIONS
AND VERIFIED ANSWERS WITH
RATIONALE RATED A+ | 2024/2025
GUIDE
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?
1. Tarry stools
2. Nausea and vomiting
3. Orange-colored urine
4. Decreased urine output
- Correct Answer - Tarry stools
Rationale: 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?
1. Ronchi
2. Wheezes
3. Crackles in the bases
4. Crackles throughout the lung fields
- Correct Answer - Crackles in the base
Rationale: 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?
1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle
- Correct Answer - Left ventricle
Rationale: 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?
, 1. "Left ventricle to aorta narrowing will impede flow of blood."
2. "Left atrium to left ventricle narrowing will impede flow of
blood."
3. "Right atrium to right ventricle narrowing will impede flow of
blood."
4. "Right ventricle to pulmonary artery narrowing will impede flow
of blood."
- Correct Answer - "Left atrium to left ventricle narrowing will
impede flow of blood."
Rationale: 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.
The registered nurse (RN) is educating a new nurse about aortic
regurgitation. Which statement by the new nurse indicates that
the teaching has been effective?
1. "Failure of the aortic valve to close completely allows blood to
flow retrograde through the aorta to the left ventricle."
2. "Failure of the aortic valve to close completely allows blood to
flow retrograde through the left ventricle to the left atrium."
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