an adult client comes to the clinic and reports his concern over a lump that just popped up on my neck about a week ago in performing an examination o
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2023

1. An adult client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

Correct answer: A

Rationale: The findings of a large, non-tender, hardened lymph node, especially in the absence of overlying tissue inflammation, are indicative of malignancy. These characteristics raise suspicion for cancer, prompting the need for further investigation. Choice B, Infection, is incorrect because infection would typically present as a tender and possibly swollen lymph node. Choice C, Benign cyst, is incorrect as cysts are usually soft and movable. Choice D, Lymphadenitis, is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes in response to an infection.

2. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?

Correct answer: A

Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.

3. A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

4. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client's instructions?

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial following a TURP procedure as it may indicate a complication such as bleeding or clot formation. This symptom requires immediate attention to prevent further complications. Choices A, C, and D are important aspects of post-TURP care, but identifying and reporting fresh blood in the urine take precedence due to its association with potential serious complications.

5. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

Similar Questions

The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?
A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value is most concerning?
A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?
The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses