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
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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. The nurse is assessing a client with left-sided heart failure. Which assessment finding is most concerning?

Correct answer: C

Rationale: Shortness of breath is the most concerning finding in a client with left-sided heart failure as it indicates worsening pulmonary congestion and impaired gas exchange. This symptom suggests that the client is experiencing significant difficulty in breathing and inadequate oxygenation, requiring immediate intervention. Jugular venous distention (Choice A) is often seen in right-sided heart failure, while peripheral edema (Choice B) and crackles in the lungs (Choice D) are common manifestations of left-sided heart failure but are not as acutely concerning as severe shortness of breath, which can rapidly progress to respiratory distress if not addressed promptly.

3. During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?

Correct answer: A

Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.

4. A client with a history of chronic kidney disease is scheduled for a renal biopsy. Which laboratory value should the nurse report to the healthcare provider before the procedure?

Correct answer: D

Rationale: A platelet count of 90,000/mm3 is low and concerning for a client scheduled for a renal biopsy, as it increases the risk of bleeding. Thrombocytopenia, indicated by a low platelet count, can lead to impaired blood clotting, posing a significant risk of bleeding during or after the biopsy procedure. Elevated serum creatinine levels may be expected in chronic kidney disease but are not directly related to bleeding risk during a renal biopsy. Prothrombin time and hemoglobin levels are not as directly relevant to the bleeding risk associated with a renal biopsy as platelet count.

5. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has become combative in the last 2 days. The mother states that the teen takes vitamins, calcium, magnesium, and aspirin. Which nursing intervention has the highest priority?

Correct answer: B

Rationale: The correct answer is to instruct the mother to take the teen to the emergency room. The symptoms described, including recurrent vomiting and becoming combative after taking vitamins, calcium, magnesium, and aspirin, indicate a potential overdose or a serious condition. Therefore, immediate medical evaluation in the emergency room is crucial. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending to withhold food and fluids (Choice C) is not appropriate in this urgent situation. Suggesting deep breathing (Choice D) does not address the seriousness of the symptoms and the need for immediate medical attention.

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A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?
A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
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