HESI Health Assessment Practice Exam
Questions and Answers
1.The registered nurse (RN) notifies the spouse of a client who
was admitted to hospice with shallow respirations, of a change
in the client's condition. Over the past hour, the client's
respiratory pattern has changed to a Cheyne Stokes pattern.
After receiving this information, the client's spouse begins
vacuuming around the bed. Which stage of grief is the spouse
displaying during the visit?
A. Acceptance
B. Denial
C. Bargaining
D. Depression
Answer B. Denial
The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's
grief model by ignoring that the client's death is imminent (A, C, and D)
are stages of grief that are not being displayed by the client's spouse
during this observation.
2.The registered nurse (RN) places an ice pack on a middle
school student who comes to the school clinic complaining of a
sprained ankle. Which ther- apeutic response should the RN
anticipate?
,A. Reduced pain and minimized bruising.
B. Lowering of body core temperature.
C. Increased circulation around injury.
D. Reabsorption of edema at injury.
Answer A.
Cold applications produce a topical anesthetic effect to reduce pain as
well as constrict blood vessels to minimize bruising (A). Local ice over an
injured area will not lower the core temperature (B). The cold pack causes
vasoconstriction which reduces circulation, not (C), to traumatized tissue
and limits further edema around the injury (D), but not by reabsorption of
edematous fluid.
3.The registered nurse (RN) palpates a weak pedal pulse on the
client'rs right foot. Which assessment findings should the RN
document that are consistent with diminished peripheral
circulation (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities.
Answer A. Diminished hair on legs
C. Skin cool to touch.
Diminished hair on the legs (A) and skin that is cool to the touch (C) are
symptoms of decreased arterial blood flow. (B, D, and E) are not
,indicators for impaired circulation.
4.Twenty four hours after a client returns from surgical gastric
bypass, the registered nurse (RN) observes large amounts of
blood in the nasogastric tube (NGT) cannister. Which
assessment finding should the RN report as early signs of
hypovolemic shock?
A. Faint pedal pulses
B. Decrease in blood pressure.
C. Lethargy.
D. Slow breathing.
Answer C. Lethargy
Changes in the level of consciousness occur in the early stages of shock
which decreases the perfusion to the brain which is manifested as
lethargy (C). The respiratory rate increases, not (D). (A and B) are late
signs of hypovolemic shock due to cardiac compensatory measures.
5.The registered nurse (RN) is caring for a client who has taken
atenolol for 2 years. The healthcare provider recently changed
the medication to enalapril to manage the client's blood
pressure. Which instruction should the RN provide the client
regarding the new medication?
A. Take the medication at bedtime.
B. Report presence of increased bruising.
C. Check pulse before taking medication.
, D. Rise slowly when getting out of bed or chair.
Answer D. Rise slowly when getting out of bed or chair.
The client's new medication is an angiotensin-converting enzyme (ACE)
inhibitor, which has the side effect of orthostatic hypotension.
Instructing the client to rise from a chair or bed slowly (D) is indicated
to avoid dizziness and falling. (A, B, and C) are not indicated when
taking an ACE inhibitor.
6.The registered nurse (RN) is assisting the healthcare
provider (HCP) with the removal of a chest tube. Which
intervention has the highest priority and should be anticipated
by the RN after removal of the chest tube?
A. Prepare the client for chest x-ray at the bedside.
B. Review arterial blood gases after removal.
C. Elevate the head of the bed to 45 degrees.
D. Assist with disassembling the drainage system.
Answer A. Prepare the client for a chest x-ray at the bedside.
A chest x-ray (A) should be performed immediately after the procedure to
ensure lung expansion has been maintained after removal of the chest
tube. (B) provides additional data after removal of the CT. (C) may assist
the client to breathe easily, but the priority after chest tube removal is to
ensure that the procedure was successful. The entire system, including
the chest tube is discarded and not taken apart (D).
7.A male client is admitted after falling from his bed. The
Questions and Answers
1.The registered nurse (RN) notifies the spouse of a client who
was admitted to hospice with shallow respirations, of a change
in the client's condition. Over the past hour, the client's
respiratory pattern has changed to a Cheyne Stokes pattern.
After receiving this information, the client's spouse begins
vacuuming around the bed. Which stage of grief is the spouse
displaying during the visit?
A. Acceptance
B. Denial
C. Bargaining
D. Depression
Answer B. Denial
The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's
grief model by ignoring that the client's death is imminent (A, C, and D)
are stages of grief that are not being displayed by the client's spouse
during this observation.
2.The registered nurse (RN) places an ice pack on a middle
school student who comes to the school clinic complaining of a
sprained ankle. Which ther- apeutic response should the RN
anticipate?
,A. Reduced pain and minimized bruising.
B. Lowering of body core temperature.
C. Increased circulation around injury.
D. Reabsorption of edema at injury.
Answer A.
Cold applications produce a topical anesthetic effect to reduce pain as
well as constrict blood vessels to minimize bruising (A). Local ice over an
injured area will not lower the core temperature (B). The cold pack causes
vasoconstriction which reduces circulation, not (C), to traumatized tissue
and limits further edema around the injury (D), but not by reabsorption of
edematous fluid.
3.The registered nurse (RN) palpates a weak pedal pulse on the
client'rs right foot. Which assessment findings should the RN
document that are consistent with diminished peripheral
circulation (Select all that apply.)
A. Diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities.
Answer A. Diminished hair on legs
C. Skin cool to touch.
Diminished hair on the legs (A) and skin that is cool to the touch (C) are
symptoms of decreased arterial blood flow. (B, D, and E) are not
,indicators for impaired circulation.
4.Twenty four hours after a client returns from surgical gastric
bypass, the registered nurse (RN) observes large amounts of
blood in the nasogastric tube (NGT) cannister. Which
assessment finding should the RN report as early signs of
hypovolemic shock?
A. Faint pedal pulses
B. Decrease in blood pressure.
C. Lethargy.
D. Slow breathing.
Answer C. Lethargy
Changes in the level of consciousness occur in the early stages of shock
which decreases the perfusion to the brain which is manifested as
lethargy (C). The respiratory rate increases, not (D). (A and B) are late
signs of hypovolemic shock due to cardiac compensatory measures.
5.The registered nurse (RN) is caring for a client who has taken
atenolol for 2 years. The healthcare provider recently changed
the medication to enalapril to manage the client's blood
pressure. Which instruction should the RN provide the client
regarding the new medication?
A. Take the medication at bedtime.
B. Report presence of increased bruising.
C. Check pulse before taking medication.
, D. Rise slowly when getting out of bed or chair.
Answer D. Rise slowly when getting out of bed or chair.
The client's new medication is an angiotensin-converting enzyme (ACE)
inhibitor, which has the side effect of orthostatic hypotension.
Instructing the client to rise from a chair or bed slowly (D) is indicated
to avoid dizziness and falling. (A, B, and C) are not indicated when
taking an ACE inhibitor.
6.The registered nurse (RN) is assisting the healthcare
provider (HCP) with the removal of a chest tube. Which
intervention has the highest priority and should be anticipated
by the RN after removal of the chest tube?
A. Prepare the client for chest x-ray at the bedside.
B. Review arterial blood gases after removal.
C. Elevate the head of the bed to 45 degrees.
D. Assist with disassembling the drainage system.
Answer A. Prepare the client for a chest x-ray at the bedside.
A chest x-ray (A) should be performed immediately after the procedure to
ensure lung expansion has been maintained after removal of the chest
tube. (B) provides additional data after removal of the CT. (C) may assist
the client to breathe easily, but the priority after chest tube removal is to
ensure that the procedure was successful. The entire system, including
the chest tube is discarded and not taken apart (D).
7.A male client is admitted after falling from his bed. The
