BSN 246 HESI HEALTH ASSESSMENT V2 ACTUAL
EXAM TEST BANK (2 SETS) – NIGHTINGALE
COLLEGE GUARANTEED PASS BUNDLE
This comprehensive 200-question test bank delivers expert-
verified practice questions directly mapped to the Nightingale
College BSN 246 health assessment curriculum. Each question
features clear stems, precise italicized correct answers, and
bolded clinical rationales designed to ensure a guaranteed pass
on your HESI V2 exam. It serves as the ultimate study guide for
nursing students looking to master physical assessment
techniques, cranial nerve pathways, and Next-Generation NCLEX
(NGN) style concepts.
Q1. A nurse is preparing to auscultate the heart
sounds of an adult client. Which landmark should
the nurse use to locate the apical pulse?
A) Second intercostal space at the right sternal
border
B) Second intercostal space at the left sternal
border
C) Fourth intercostal space at the left sternal
border
D) Fifth intercostal space at the left midclavicular
line
Answer: D) Fifth intercostal space at the left
midclavicular line
,Rationale: The apex of the heart and the mitral area
(apical pulse) are anatomically located at the fifth
intercostal space along the left midclavicular line.
Option A defines the aortic area, Option B defines
the pulmonic area, and Option C defines the
tricuspid area.
Q2. While conducting a physical assessment, the
nurse prepares to listen to high-pitched bowel
sounds. Which part of the stethoscope is most
appropriate?
A) The bell with firm pressure
B) The diaphragm with light pressure
C) The diaphragm with firm pressure
D) The bell with light pressure
Answer: C) The diaphragm with firm pressure
Rationale: The diaphragm of the stethoscope is
designed to detect high-pitched sounds (such as
bowel, lung, and normal heart sounds) and must be
held firmly against the skin. The bell is used with
light pressure to capture low-pitched sounds, such
as vascular bruits or murmurs.
Q3. A nurse is documenting a client's health history.
Which entry correctly reflects the client's "chief
complaint"?
,A) Client appears anxious and reports feeling short
of breath.
B) Client states, "I have had a sharp pain in my
chest for the last two hours."
C) Client has a history of myocardial infarction and
hypertension.
D) Objective data shows a heart rate of 112 beats per
minute.
Answer: B) Client states, "I have had a sharp pain in
my chest for the last two hours."
Rationale: The chief complaint must always be
documented as a direct quote from the client,
stating their exact subjective reason for seeking
medical care, including the duration of symptoms.
Options A, C, and D contain clinical synthesis,
medical history, or objective data.
Q4. During a musculoskeletal assessment, the
nurse asks the client to move their arm away from
the midline of the body. The nurse is assessing
which range of motion (ROM) movement?
A) Adduction
B) Abduction
C) Circumduction
D) Extension
, Answer: B) Abduction
Rationale: Abduction is the movement of a limb
away from the midline of the body. Adduction moves
the limb toward the midline. Extension increases
the angle between bones, and circumduction is a
circular movement.
Q5. While performing a neurological exam, the
nurse strikes the patellar tendon and notes an
exaggerated, hyperactive reflex with transient
clonus. How should the nurse document this
finding?
A) 1+
B) 2+
C) 3+
D) 4+
Answer: D) 4+
Rationale: Deep tendon reflexes are graded on a 0
to 4+ scale. A grade of 4+ indicates a hyperactive,
brisk response that is often accompanied by clonus,
indicating upper motor neuron disease. 2+ is
normal, 1+ is diminished, and 3+ is brisker than
average but not necessarily pathological.
EXAM TEST BANK (2 SETS) – NIGHTINGALE
COLLEGE GUARANTEED PASS BUNDLE
This comprehensive 200-question test bank delivers expert-
verified practice questions directly mapped to the Nightingale
College BSN 246 health assessment curriculum. Each question
features clear stems, precise italicized correct answers, and
bolded clinical rationales designed to ensure a guaranteed pass
on your HESI V2 exam. It serves as the ultimate study guide for
nursing students looking to master physical assessment
techniques, cranial nerve pathways, and Next-Generation NCLEX
(NGN) style concepts.
Q1. A nurse is preparing to auscultate the heart
sounds of an adult client. Which landmark should
the nurse use to locate the apical pulse?
A) Second intercostal space at the right sternal
border
B) Second intercostal space at the left sternal
border
C) Fourth intercostal space at the left sternal
border
D) Fifth intercostal space at the left midclavicular
line
Answer: D) Fifth intercostal space at the left
midclavicular line
,Rationale: The apex of the heart and the mitral area
(apical pulse) are anatomically located at the fifth
intercostal space along the left midclavicular line.
Option A defines the aortic area, Option B defines
the pulmonic area, and Option C defines the
tricuspid area.
Q2. While conducting a physical assessment, the
nurse prepares to listen to high-pitched bowel
sounds. Which part of the stethoscope is most
appropriate?
A) The bell with firm pressure
B) The diaphragm with light pressure
C) The diaphragm with firm pressure
D) The bell with light pressure
Answer: C) The diaphragm with firm pressure
Rationale: The diaphragm of the stethoscope is
designed to detect high-pitched sounds (such as
bowel, lung, and normal heart sounds) and must be
held firmly against the skin. The bell is used with
light pressure to capture low-pitched sounds, such
as vascular bruits or murmurs.
Q3. A nurse is documenting a client's health history.
Which entry correctly reflects the client's "chief
complaint"?
,A) Client appears anxious and reports feeling short
of breath.
B) Client states, "I have had a sharp pain in my
chest for the last two hours."
C) Client has a history of myocardial infarction and
hypertension.
D) Objective data shows a heart rate of 112 beats per
minute.
Answer: B) Client states, "I have had a sharp pain in
my chest for the last two hours."
Rationale: The chief complaint must always be
documented as a direct quote from the client,
stating their exact subjective reason for seeking
medical care, including the duration of symptoms.
Options A, C, and D contain clinical synthesis,
medical history, or objective data.
Q4. During a musculoskeletal assessment, the
nurse asks the client to move their arm away from
the midline of the body. The nurse is assessing
which range of motion (ROM) movement?
A) Adduction
B) Abduction
C) Circumduction
D) Extension
, Answer: B) Abduction
Rationale: Abduction is the movement of a limb
away from the midline of the body. Adduction moves
the limb toward the midline. Extension increases
the angle between bones, and circumduction is a
circular movement.
Q5. While performing a neurological exam, the
nurse strikes the patellar tendon and notes an
exaggerated, hyperactive reflex with transient
clonus. How should the nurse document this
finding?
A) 1+
B) 2+
C) 3+
D) 4+
Answer: D) 4+
Rationale: Deep tendon reflexes are graded on a 0
to 4+ scale. A grade of 4+ indicates a hyperactive,
brisk response that is often accompanied by clonus,
indicating upper motor neuron disease. 2+ is
normal, 1+ is diminished, and 3+ is brisker than
average but not necessarily pathological.
