Question 1
HESI Exit Exam. After a young adult woman describes feeling palpitations when she lies on her left side, it is most important for the nurse to auscultate heart sounds at which anatomical location?
- A Left third intercostal space, left lateral sternal border.
- B Base of the heart at second intercostal space, right of the sternal border.
- C Apex of the heart at left fifth intercostal space at the midclavicular line.
- D Second intercostal space, left of the sternal border.
Question 2
The nurse is assessing the patient to develop the plan of care. Complete the diagram by dragging from the choices area to specify which potential condition the client is possibly experiencing, two actions the nurse should take when assessing the carotid arteries, and two parameters the nurse should continually monitor post initial findings.
Potential Conditions
- Arterial obstruction or aneurysm
Actions to Take
- Assess with bell of stethoscope
- Compress gently one carotid at a time
Parameters to Monitor
- Pulses
- Murmur
Question 3
During the health history, a client describes a symptom to the nurse. Which information about the symptom is best obtained by use of a numeric scale?
- A Severity.
- B Quality.
- C Radiation.
- D Timing.
Question 4
The nurse notes an enlarged, visible lymph node on the client’s neck. Which action should the nurse take next?
- A Cover the inflamed area and notify the healthcare provider.
- B Auscultate the lymph node for the presence of a bruit.
- C Ask the client about any localized tenderness at the site.
- D Record this normal finding in the assessment record.
Question 5
When assessing an older adult client, which finding is most indicative of dehydration?
- A Tenting noted in subclavicular area.
- B Loss of skin elasticity in the hand.
- C Thinning hair in the lower extremities.
- D Skin is warm and dry.
Question 6
The nurse is performing a pulmonary assessment for an adult who arrives at the clinic for an annual physical examination. Which assessment findings should the nurse identify as a normal finding?
- A The accessory muscles are used during inspiration and expiration.
- B The thorax is barrel shaped.
- C The ribs articulate at a 45-degree angle with the sternum.
- D The costal margin is greater than 90 degrees.
Hepatomegaly Documentation
A nurse is assessing a client’s abdomen for hepatomegaly. Which finding should the nurse document?
- A Areas of tympany within the liver region
- B Tympany noted boarding the margins of the liver
- C A hollow sound over the lower abdomen
- D A dull percussion tone outside the costal margins
Abdominal Auscultation
A nurse is assessing a client’s abdomen. Which of the following findings does the nurse assess using auscultation?
- A Ascites
- B Bruits
- C Guarding
- D Striae
Skin Turgor Assessment
A nurse is assessing a client’s skin turgor. After pinching a large fold of skin over the sternum, which of the following actions should the nurse perform next?
- A Release and observe how quickly the skin returns to normal.
- B Measure the depth of the pitting in the skin.
- C Inspect the color and texture of the skin area.
- D Document how easily the skin area is raised.
Tuning Fork Usage
A nurse is performing a physical examination of a client. For which of the following purposes should the nurse use a tuning fork?
- A Otitis media
- B Hearing loss
- C Neurological pathology
- D Tinnitus
Shoulder Range of Motion
A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client’s shoulder, which assessment technique should the nurse ask the client to perform?
- A Extend arms up to 180 degrees beside the ears.
- B Alternate both index fingers to touch the tip of nose accurately.
- C Hold arms up at 90 degrees while arms are pushed downward.
- D Extend arms straight out and hold without drifting.
Neurological Assessment Diagram
Complete the diagram by dragging from the choices below the actions to take, potential condition, and parameters to monitor. (Based on Stroke Case Study)
Row 1:
- Action to Take: Assess movement of facial expressions
- Potential Condition: Cranial Nerve VII
- Parameter to Monitor: Taste
Row 2:
- Action to Take: Assess lateral eye movement
- Potential Condition: Cranial Nerve VI
- Parameter to Monitor: Lateral eye movement
Question 13
When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?
- A. The client has a collapsed lung.
- B. The client’s lungs are functioning normally.
- C. There is a history of chronic obstructive pulmonary disease.
- D. A chronic lung infection is the likely condition.
- A
Question 14
In assessing a client’s nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?
- A. Administer a PRN prescription for oxygen.
- B. Determine the client’s most recent hemoglobin level.
- C. Consult with a podiatrist to trim the client’s toenails.
- D. Document the presence of nailbed clubbing.
- D
Question 15
In assessing a client’s muscle strength in the arms, the nurse observes as the client flexes both elbows fully and smoothly. Which action should the nurse take next?
- A. Observe the client’s ability to smoothly adduct both forearms.
- B. Apply opposing force to the forearms while the client resists.
- C. Ask the client to lift both arms straight over the head.
- D. Document the findings in the electronic medical record.
- B
Question 17
A client arrives at the clinic and describes having rectal pressure, burning, and itching around the anus. During the health assessment, which technique should the nurse implement to determine if the client has hemorrhoids?
- A. Ask client to bear down while observing for rectal protrusions.
- B. Turn client laterally to palpate Bartholin’s glands.
- C. Obtain a stool sample to assess for occult blood.
- D. Inspect anus as the client bends over and touches the floor.
- A
Question 18
The nurse observes generalized weakness and diminished deep tendon reflexes on the right side of an older adult client who has a history of a cerebrovascular accident (CVA). Which deep tendon reflex response should the nurse document to support the client’s clinical assessment?
- A. Right side deep tendon reflex 4+.
- B. Right side deep tendon reflex 1+.
- C. Right side deep tendon reflex 2+.
- D. Right side deep tendon reflex 0.
- B
Question 19
In assessing a client’s heart sounds, the nurse hears an $S_1$ and $S_2$ after placing the diaphragm of the stethoscope at the second intercostal space just to the right of the sternum while the client is supine in bed. Which action should the nurse take next?
- A. Document the presence of normal heart sounds in the client’s chart.
- B. Assist the client to turn to a left side-lying position in the bed.
- C. Inch the stethoscope down the right side of the sternum.
- D. Move the diaphragm of the stethoscope to the left of the sternum.
- D
Question 20
The nurse strokes the lateral side of the sole and across the ball of the foot with the end of a reflex hammer. The client’s toes curl downward. Which action should the nurse perform next?
- A. Continue stroking down the medial side of the foot.
- B. Notify the healthcare provider of the presence of a positive Babinski reflex.
- C. Repeat the same motion with the flat portion of the reflex hammer.
- D. Document the expected response of plantar flexion in the medical record.
- D
Question 21
The nurse is assessing a client for a goiter and is unable to observe the thyroid gland. Which action should the nurse take next?
- A. Palpate deeply and firmly over the location of the thyroid gland.
- B. Document that thyroid gland size is normal with no visible goiter.
- C. Defer the thyroid exam and observe the client for signs of myxedema.
- D. Ask the client to swallow while palpating along the sides of the trachea.
- D
Question 22
The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.
- A. Glasgow coma scale
- B. Cranial nerves
- C. Pupil size
- D. Muscle tone
- E. Level of consciousness
- F. Brudzinski reflexes
- G. Romberg’s test
Question 23 of 60
To compare arterial circulation in a client’s lower extremities, which assessment should the nurse complete?
- A Observe plantar flexion and dorsiflexion.
- B Compress the tissue around the ankles.
- C Stroke the soles and note toe movement.
- D Palpate the volume of the pedal pulses.
Question 24 of 60
When assessing a client’s mouth, which finding requires immediate follow-up by the nurse?
- A Buccal mucosa ulceration.
- B Gingival inflammation.
- C White, curd-like lesions.
- D Fruity odor of the breath.
Question 25 of 60
The nurse is performing a mental status examination and asks an adult client to interpret a familiar proverb. When the client is unable to interpret the proverb, the nurse repeats the instructions and the client is still unable to accurately interpret it. Which action should the nurse implement?
- A Document client’s difficulty with abstract reasoning.
- B Provide a different proverb for the client to interpret.
- C Explain the meaning of the proverb and ask the client to repeat it.
- D Reschedule the exam for another time.
Question 26 of 60
A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?
- A Circulation impaired.
- B Reports feeling “on fire.”
- C Inflammation present.
- D Paresthesia reported.
Question 28 of 60
A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question is best for the nurse to ask this client?
- A “What brought you to the clinic?”
- B “What type of surgery did you have?”
- C “Are you having any pain?”
- D “When did your surgery take place?”
Question 30 of 60
After checking a client’s pupillary response to light, the practical nurse (PN) tells the registered nurse (RN) that the client’s pupils are constricted with minimal response to light. Before verifying the PN’s findings, which action should the RN take?
- A Administer PRN saline eye solution.
- B Brighten the light in the client’s room.
- C Assess the client’s visual fields.
- D Review the client’s medication list.
Question 31 of 60
During assessment of the thorax and lungs, which technique should the nurse use to assess a client’s anteroposterior (AP) diameter?
- A Auscultation.
- B Palpation.
- C Inspection.
- D Percussion.
Question 37 of 60
The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual’s nutritional status?
- A History of a recent weight loss.
- B A 24 hour diet history.
- C Status of current appetite.
- D Condition of hair, nails, and skin.
Question 38 of 60
An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirms the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.
- A Intercostal retractions.
- B Headaches.
- C Dyspnea.
- D Peripheral edema.
- E Jugular venous distension.
Question 39 of 60
The nurse examines a client who is concerned about the amount of menstrual flow she is having. Which finding indicates an abnormality related to the client’s current menstruation?
- A Blood clots sized at 0.5 cm (0.2 in) with menstrual flow.
- B Blood saturation of one pad an hour.
- C An odorless, red menstrual blood flow.
- D Cramping associated with the amount of flow.
Question 40 of 60
To confirm the presence of steatorrhea, which action should the nurse take? HESI Exit Exam
- A Observe the appearance of the client’s stool.
- B Lightly palpate areas of abdominal protuberance.
- C Inspect the area around the client’s umbilicus.
- D Auscultate all quadrants of the client’s abdomen.
Question 41 of 60
A nurse is completing the health history for a 25-year-old male client who reports that he is allergic to penicillin. Which question should the nurse ask after receiving this information?
- A “Are you allergic to any other medications?”
- B “Is anyone else in your family allergic to penicillin?”
- C “What happens to you when you take penicillin?”
- D “How often have you taken penicillin in the past?”
Question 42 of 60
Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.
- A Reach under a gown to listen and take care that no clothing rubs on the stethoscope
- B Document the roaring and crackles
- C Keep the examination room warm, and warm the stethoscope
- D Ensure the room is as quiet as possible
- E Wet the chest hair before auscultating
Question 39
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which action should the nurse take to help confirm the presence of a barrel chest?
- A. Percuss the lung fields for hyperresonance.
- B. Auscultate for diminished breath sounds.
- C. Observe the appearance of the thorax.
- D. Palpate for tactile fremitus.
Question 40
During an ophthalmoscopic examination, the nurse observes a red glow in the client’s pupils. What action should the nurse take?
- A. Refer the client to an ophthalmologist.
- B. Position the client for a better view.
- C. Continue the examination.
- D. Document the presence of cataracts.
Question 41
A client’s legs are asymmetrical. What is the nurse’s next action?
- A. Test the passive range of motion of each leg.
- B. Compare the circumference of each calf.
- C. Observe the client’s gait while walking.
- D. Measure the length of each leg and document the findings.
Question 42
The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual’s nutritional status?
- A. History of a recent weight loss.
- B. Status of current appetite.
- C. Condition of hair, nails, and skin.
- D. A 24 hour diet history.
Question 43
The nurse is inspecting a client’s skin. Which primary skin lesions contain a fluid-like substance? (Select all that apply.)
- A. Tumor.
- B. Nodule.
- C. Papule.
- D. Wheal.
- E. Macule.
- F. Pustule.
- G. Vesicle.
Question 44
The nurse places the diaphragm of the stethoscope at the second intercostal space just to the right of the sternum and hears $S_1$ and $S_2$ heart sounds. Which action should the nurse take next? HESI Exit Exam
- A. Document the findings in the electronic medical record.
- B. Progress down the right side of the sternum to the third intercostal space.
- C. Turn the client to the left side-lying position.
- D. Move the diaphragm of the stethoscope to the left of the sternum.
Question 45
The nurse is performing a skin assessment. Which finding requires the most immediate follow-up?
- A. Generalized truncal rash.
- B. Thickened yellow nailbeds.
- C. Diminished hair growth on legs.
- D. Plaque formation on elbows.
Question 46
The nurse is performing a musculoskeletal assessment of an older adult. Which assessment is most important to determine the client’s safety in the home?
- A. Assess for the presence of scoliosis.
- B. Observe gait while walking.
- C. Check for symmetry of the shoulders.
- D. Inspect for nodules on the finger joints.
Question 47
The nurse is conducting a mental status examination. After repeating the instructions, the nurse asks the client to interpret a proverb, but the client is unable to do so. Which action should the nurse take?
- A. Explain the meaning of the proverb to the client.
- B. Reschedule the exam for a later time.
- C. Provide the client with a different proverb.
- D. Document client’s difficulty with abstract reasoning.
Question 48
A client is admitted to the hospital with a diagnosis of heart failure (HF). Which findings confirm the client is experiencing an exacerbation of HF? (Select all that apply.)
- A. Jugular venous distension.
- B. Peripheral edema.
- C. Intercostal retractions.
- D. Headaches.
- E. Dyspnea.
Question 49
The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?
- A. Very loud, with no stethoscope, thrill easily palpable, heave visible.
- B. Soft, barely heard on auscultation in a quiet room.
- C. Moderately loud, machine-like rumble, not associated with a thrill.
- D. Loud, at the apex, associated with a palpable thrill.
Question 50
Which action should the nurse take to assess a client’s response to painful stimuli who has a marked reduction in the level of consciousness?
- A. Use aromatic spirits of peppermint.
- B. Press firmly on the center of the sternum.
- C. Run a pointed object up the sole of foot.
- D. Shake and call the client’s name.
Question 51
Which assessment finding requires the most immediate follow-up by the nurse?
- A. Cyanotic nailbeds.
- B. Dependent rubor.
- C. Ankle ulceration.
- D. Purulent sputum.
Question 43
While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?
- A The gallbladder is normal.
- B Palpating in the wrong abdominal quadrant.
- C Deeper palpation technique is needed.
- D The client is too obese.
Question 44
An older adult male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?
- A Observe the scrotum for swelling.
- B Question the client about related symptoms.
- C Palpate the inguinal area for a bulge.
- D Inspect the urethral meatus for discharge.
Question 45
The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?
- A Observe gait while walking.
- B Compare shoulder symmetry.
- C Palpate for joint nodules.
- D Assess for spinal scoliosis.
Question 46
An older client reports difficulty reading due to blurred and distorted vision. The nurse should review the electronic medical record for which risk factor?
- A Cigarette smoking.
- B Pancreatitis.
- C Osteoporosis.
- D Alcohol use.
Question 47
The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?
- A Very loud, with no stethoscope, thrill easily palpable, heave visible.
- B Soft, barely heard on auscultation in a quiet room.
- C Moderately loud, machine-like rumble, not associated with a thrill.
- D Loud, at the apex, associated with a palpable thrill.
Question 48
Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?
- A Shake and call the client’s name.
- B Run a pointed object up the sole of foot.
- C Press firmly on the center of the sternum.
- D Use aromatic spirits of peppermint.
Question 49
The nurse inserts an otoscope into a client’s ear canal. Which assessment technique is the nurse performing?
- A Auscultation.
- B Percussion.
- C Palpation.
- D Inspection.
