2026 HESI HEALTH ASSESSMENT EXAM VERSION 3
LATEST ACTUAL EXAM ALL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+.
#VERSION 3
Question 1
During the percussion assessment of a 4-year-old child's lungs, the nurse hears
bilateral tones that are louder, longer, and lower in pitch than expected. Based on
this finding, what is the most appropriate next action for the nurse to take?
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the
examination.
Correct Answer: D
Expert Rationale
The pediatric chest presents unique anatomical and physiological characteristics
that significantly influence the findings of a physical examination. In children,
particularly those under the age of 5, the chest wall is thinner and more compliant
than in adults. The ribs are more horizontally positioned, and the intercostal
muscles are less developed. These factors result in a more resonant percussion note
that is typically louder, longer, and lower in pitch compared to the adult chest. This
finding is considered a normal developmental variant and reflects the increased air
content relative to the smaller amount of tissue mass. The presence of bilateral
symmetrical hyperresonance in a child without other signs of respiratory distress,
fever, or cough is an expected finding and does not indicate pathology. The nurse
,should recognize this as a normal physiological characteristic of the pediatric
thorax and proceed with the remainder of the examination.
Option A is incorrect because palpation for pain and tenderness is not indicated
when the percussion tone is a normal variant. Pain assessment would be
appropriate if there were other signs of pathology, but this finding alone does not
warrant further invasive assessment.
Option B is incorrect because asking the child to take shallow breaths and
repeating the percussion would not provide additional useful information. The
finding is normal and does not require reassessment with altered breathing
patterns.
Option C is incorrect because an immediate referral is not warranted. While
hyperresonance can be a sign of increased air trapping in conditions such as
asthma or emphysema, this is a normal finding in a child of this age and does not
indicate pathology.
DIF: Cognitive Level: Apply
TOP: Pediatric Assessment: Chest Percussion
MSC: Health Promotion and Maintenance
Question 2
A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After notifying the physician and placing the
patient on supplemental oxygen, which of the following actions represents the best
approach for the nurse to take when assessing the patient further?
a. Count the patient's respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
Correct Answer: B
Expert Rationale
When a patient presents with acute respiratory distress, a comprehensive and
systematic assessment is essential to identify the underlying cause and guide
,appropriate interventions. After the initial management steps of notifying the
physician and administering oxygen, the nurse should proceed with a thorough
physical assessment. Percussion of the thorax bilaterally is a critical component of
this assessment because it can reveal important information about the underlying
lung condition. Normal lung tissue produces a resonant percussion note. Dullness
on percussion may indicate the presence of fluid (as in pleural effusion),
consolidation (as in pneumonia), or a mass. Hyperresonance may indicate trapped
air (as in emphysema or pneumothorax). By comparing the percussion tones
bilaterally, the nurse can identify asymmetrical findings that may point to the
etiology of the respiratory distress. This assessment provides immediate, bedside
information that can guide clinical decision-making while awaiting further
diagnostic studies.
Option A is incorrect because while counting respirations is a component of the
respiratory assessment, it is insufficient in a patient with acute distress. The nurse
needs to gather more comprehensive data about the quality and character of breath
sounds, percussion tones, and other physical findings.
Option C is incorrect because waiting for a chest x-ray before beginning an
assessment would delay potentially life-saving interventions. The physical
assessment can provide immediate information that may guide treatment while the
x-ray is being obtained.
Option D is incorrect because while inspection is an important part of the physical
assessment, it is limited to visual findings. The nurse should also perform
palpation and percussion to gather more comprehensive data about the patient's
respiratory status.
DIF: Cognitive Level: Analyze
TOP: Respiratory Assessment: Percussion
MSC: Physiological Integrity: Physiological Adaptation
Question 3
The nurse is teaching a class on basic assessment skills to a group of nursing
students. Which of the following statements is true regarding the stethoscope and
its proper use in clinical practice?
, a. The slope of the earpieces should point posteriorly (toward the occiput).
b. The stethoscope does not magnify sound but does block out extraneous room
noise.
c. The fit and quality of the stethoscope are not as important as its ability to
magnify sound.
d. The ideal tubing length should be 22 inches to dampen distortion of sound.
Correct Answer: B
Expert Rationale
The stethoscope is one of the most fundamental and frequently used instruments in
clinical practice. Understanding its proper use and function is essential for accurate
physical assessment. The stethoscope functions by transmitting sound waves from
the patient's body through the tubing to the examiner's ears. Importantly, the
stethoscope does not magnify sound; rather, it serves as a conduit that transmits
sound while blocking out extraneous ambient noise. This allows the examiner to
focus on the specific sounds of interest, such as heart sounds, breath sounds, or
bowel sounds. The ability to block out room noise is one of the stethoscope's most
valuable features, as it enables the examiner to detect subtle sounds that might
otherwise be missed.
Option A is incorrect because the slope of the earpieces should point anteriorly
(toward the nose), not posteriorly. This positioning aligns the earpieces with the
natural curve of the ear canal, allowing for optimal sound transmission and
comfort.
Option C is incorrect because the fit and quality of the stethoscope are extremely
important. A poorly fitting stethoscope or one of low quality can compromise the
examiner's ability to hear subtle sounds, potentially leading to missed findings or
inaccurate assessments. The stethoscope's ability to magnify sound is not its
primary function; rather, it is to transmit sound effectively.
Option D is incorrect because the ideal tubing length for a stethoscope is typically
12 to 18 inches. Tubing that is 22 inches long can increase the risk of sound
distortion and may not provide optimal sound transmission. Shorter tubing reduces
the potential for artifact and provides more direct sound transmission.
DIF: Cognitive Level: Understand
TOP: Physical Assessment: Stethoscope Use
MSC: Health Promotion and Maintenance
LATEST ACTUAL EXAM ALL QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+.
#VERSION 3
Question 1
During the percussion assessment of a 4-year-old child's lungs, the nurse hears
bilateral tones that are louder, longer, and lower in pitch than expected. Based on
this finding, what is the most appropriate next action for the nurse to take?
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the
examination.
Correct Answer: D
Expert Rationale
The pediatric chest presents unique anatomical and physiological characteristics
that significantly influence the findings of a physical examination. In children,
particularly those under the age of 5, the chest wall is thinner and more compliant
than in adults. The ribs are more horizontally positioned, and the intercostal
muscles are less developed. These factors result in a more resonant percussion note
that is typically louder, longer, and lower in pitch compared to the adult chest. This
finding is considered a normal developmental variant and reflects the increased air
content relative to the smaller amount of tissue mass. The presence of bilateral
symmetrical hyperresonance in a child without other signs of respiratory distress,
fever, or cough is an expected finding and does not indicate pathology. The nurse
,should recognize this as a normal physiological characteristic of the pediatric
thorax and proceed with the remainder of the examination.
Option A is incorrect because palpation for pain and tenderness is not indicated
when the percussion tone is a normal variant. Pain assessment would be
appropriate if there were other signs of pathology, but this finding alone does not
warrant further invasive assessment.
Option B is incorrect because asking the child to take shallow breaths and
repeating the percussion would not provide additional useful information. The
finding is normal and does not require reassessment with altered breathing
patterns.
Option C is incorrect because an immediate referral is not warranted. While
hyperresonance can be a sign of increased air trapping in conditions such as
asthma or emphysema, this is a normal finding in a child of this age and does not
indicate pathology.
DIF: Cognitive Level: Apply
TOP: Pediatric Assessment: Chest Percussion
MSC: Health Promotion and Maintenance
Question 2
A patient has suddenly developed shortness of breath and appears to be in
significant respiratory distress. After notifying the physician and placing the
patient on supplemental oxygen, which of the following actions represents the best
approach for the nurse to take when assessing the patient further?
a. Count the patient's respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
Correct Answer: B
Expert Rationale
When a patient presents with acute respiratory distress, a comprehensive and
systematic assessment is essential to identify the underlying cause and guide
,appropriate interventions. After the initial management steps of notifying the
physician and administering oxygen, the nurse should proceed with a thorough
physical assessment. Percussion of the thorax bilaterally is a critical component of
this assessment because it can reveal important information about the underlying
lung condition. Normal lung tissue produces a resonant percussion note. Dullness
on percussion may indicate the presence of fluid (as in pleural effusion),
consolidation (as in pneumonia), or a mass. Hyperresonance may indicate trapped
air (as in emphysema or pneumothorax). By comparing the percussion tones
bilaterally, the nurse can identify asymmetrical findings that may point to the
etiology of the respiratory distress. This assessment provides immediate, bedside
information that can guide clinical decision-making while awaiting further
diagnostic studies.
Option A is incorrect because while counting respirations is a component of the
respiratory assessment, it is insufficient in a patient with acute distress. The nurse
needs to gather more comprehensive data about the quality and character of breath
sounds, percussion tones, and other physical findings.
Option C is incorrect because waiting for a chest x-ray before beginning an
assessment would delay potentially life-saving interventions. The physical
assessment can provide immediate information that may guide treatment while the
x-ray is being obtained.
Option D is incorrect because while inspection is an important part of the physical
assessment, it is limited to visual findings. The nurse should also perform
palpation and percussion to gather more comprehensive data about the patient's
respiratory status.
DIF: Cognitive Level: Analyze
TOP: Respiratory Assessment: Percussion
MSC: Physiological Integrity: Physiological Adaptation
Question 3
The nurse is teaching a class on basic assessment skills to a group of nursing
students. Which of the following statements is true regarding the stethoscope and
its proper use in clinical practice?
, a. The slope of the earpieces should point posteriorly (toward the occiput).
b. The stethoscope does not magnify sound but does block out extraneous room
noise.
c. The fit and quality of the stethoscope are not as important as its ability to
magnify sound.
d. The ideal tubing length should be 22 inches to dampen distortion of sound.
Correct Answer: B
Expert Rationale
The stethoscope is one of the most fundamental and frequently used instruments in
clinical practice. Understanding its proper use and function is essential for accurate
physical assessment. The stethoscope functions by transmitting sound waves from
the patient's body through the tubing to the examiner's ears. Importantly, the
stethoscope does not magnify sound; rather, it serves as a conduit that transmits
sound while blocking out extraneous ambient noise. This allows the examiner to
focus on the specific sounds of interest, such as heart sounds, breath sounds, or
bowel sounds. The ability to block out room noise is one of the stethoscope's most
valuable features, as it enables the examiner to detect subtle sounds that might
otherwise be missed.
Option A is incorrect because the slope of the earpieces should point anteriorly
(toward the nose), not posteriorly. This positioning aligns the earpieces with the
natural curve of the ear canal, allowing for optimal sound transmission and
comfort.
Option C is incorrect because the fit and quality of the stethoscope are extremely
important. A poorly fitting stethoscope or one of low quality can compromise the
examiner's ability to hear subtle sounds, potentially leading to missed findings or
inaccurate assessments. The stethoscope's ability to magnify sound is not its
primary function; rather, it is to transmit sound effectively.
Option D is incorrect because the ideal tubing length for a stethoscope is typically
12 to 18 inches. Tubing that is 22 inches long can increase the risk of sound
distortion and may not provide optimal sound transmission. Shorter tubing reduces
the potential for artifact and provides more direct sound transmission.
DIF: Cognitive Level: Understand
TOP: Physical Assessment: Stethoscope Use
MSC: Health Promotion and Maintenance
