BSN 246 HESI V2 health assessment Exam|| Most
Recent Exam 2026 | Actual Complete Real Exam
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Newest Exam \ Nightingale College
In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic.
Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or
color. This generally is due to either a lock of oxygen in the blood or to
extremely cold temperatures. When the skin becomes a bluish color, the
symptom is called cyanosis. Most commonly, blue lips are caused by a lack of
oxygen in the blood. Most causes of cyanosis are serious and symptom of your body
not getting enough oxygen. Over time, this condition will become life-
threatening. It can lead to respiratory failure, heart failure, and even death, if left
untreated.
,While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client's
respirators are regular and deep, and his respiratory rate is 14 breaths/minutes.
What is the best nursing action?
A. Ask the client to perform light exercise and observe the respiratory effect.
B. Document "dyspnea on exertion" in the client's medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or "shortness of breath."
Correct answer is C. Both respiratory rate and breath sounds are normal. Further
assessment is needed by asking the client to describe his SOB
When assessing a male client's respiratory status, which technique should the
nurse use to assess his anterior- posterior (AP) chest diameter? A. Auscultation. B.
Percussion. C. Palpation. D. Observation.
Correct answer is D. Observation is the way to detect barrel chest which is
associated with COPD
Which assessment finding supports the client statement, "My feet swell all the
time?" A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet > 3
seconds. C. Pedal pulses weak and thread. D. Positive Homan's sign bilaterally.
Correct answer is A. 2+ pitting edema indicate swelling in the lower extremities.
Homans's sign is often used in the diagnosis of deep venous thrombosis of the
leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to
be associated with the presence of thrombosis.
, The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a
high frequency hearing loss, and a reduced gag reflex. What action should the
nurse take next? A. Review past history for any episodes of a cerebral cortex
lesion. B. Implement neuro vital signs every 2 hours to detect Cushing's Triad. C.
Continue the assessment to the next pairs of cranial nerves. D. Assess the spinal
reflexes for demyelination symptoms.
Correct answer is C. Full cranial nurses assessment should be completed before
considering the other options.
When performing a neurologic assessment on an alert client, the nurse observes
that the client's pupils are both round, 3 mm in size, and respond briskly to light.
Which notation should the nurse use when documenting the assessment? A.
PERRL. B. GCS of 15. C. PERLA. D. Neuro status intact
Correct answer is A. "Pupils Equal, Round, and Reactive to Light".
Which assessment technique provides the nurse with the best data related to the
client's level of peripheral perfusion?
correct answer C. Capillary refill test
Recent Exam 2026 | Actual Complete Real Exam
Questions With 100% Correct Answers | Verified
Answers | Already Graded A+ | Guaranteed Success!! |
Newest Exam \ Nightingale College
In observing a client's face, which assessment finding requires the most
immediate intervention by the nurse?
A. Eyelids are matted and crusted.
B. Cornea are jaundiced.
C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic.
Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or
color. This generally is due to either a lock of oxygen in the blood or to
extremely cold temperatures. When the skin becomes a bluish color, the
symptom is called cyanosis. Most commonly, blue lips are caused by a lack of
oxygen in the blood. Most causes of cyanosis are serious and symptom of your body
not getting enough oxygen. Over time, this condition will become life-
threatening. It can lead to respiratory failure, heart failure, and even death, if left
untreated.
,While obtaining a health history, a male client tells the nurse that he sometimes
experiences shortness of breath. The nurse determines that the client's
respirators are regular and deep, and his respiratory rate is 14 breaths/minutes.
What is the best nursing action?
A. Ask the client to perform light exercise and observe the respiratory effect.
B. Document "dyspnea on exertion" in the client's medical record.
C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or "shortness of breath."
Correct answer is C. Both respiratory rate and breath sounds are normal. Further
assessment is needed by asking the client to describe his SOB
When assessing a male client's respiratory status, which technique should the
nurse use to assess his anterior- posterior (AP) chest diameter? A. Auscultation. B.
Percussion. C. Palpation. D. Observation.
Correct answer is D. Observation is the way to detect barrel chest which is
associated with COPD
Which assessment finding supports the client statement, "My feet swell all the
time?" A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet > 3
seconds. C. Pedal pulses weak and thread. D. Positive Homan's sign bilaterally.
Correct answer is A. 2+ pitting edema indicate swelling in the lower extremities.
Homans's sign is often used in the diagnosis of deep venous thrombosis of the
leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to
be associated with the presence of thrombosis.
, The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse
notes that the client has a reduced upward gaze, a decreased corneal reflex, a
high frequency hearing loss, and a reduced gag reflex. What action should the
nurse take next? A. Review past history for any episodes of a cerebral cortex
lesion. B. Implement neuro vital signs every 2 hours to detect Cushing's Triad. C.
Continue the assessment to the next pairs of cranial nerves. D. Assess the spinal
reflexes for demyelination symptoms.
Correct answer is C. Full cranial nurses assessment should be completed before
considering the other options.
When performing a neurologic assessment on an alert client, the nurse observes
that the client's pupils are both round, 3 mm in size, and respond briskly to light.
Which notation should the nurse use when documenting the assessment? A.
PERRL. B. GCS of 15. C. PERLA. D. Neuro status intact
Correct answer is A. "Pupils Equal, Round, and Reactive to Light".
Which assessment technique provides the nurse with the best data related to the
client's level of peripheral perfusion?
correct answer C. Capillary refill test
