BSN 246 HESI HEALTH ASSESSMENT V4
2026/2027 | Nightingale College |
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Graded
1. Which action can appropriately be delegated to UAP?
A. Perform the initial nursing assessment
B. Develop the nursing care plan
C. Measure and document routine urinary output
D. Evaluate the patient's response to medication
CORRECT ANSWER: C
Rationale:
Routine measurement of urinary output can generally be delegated when the patient is stable
and the task falls within the UAP's scope. Assessment, care planning, and evaluation remain
nursing responsibilities.
2. A patient reports abdominal pain. What is the nurse's best initial response?
A. “You should take your prescribed medication.”
B. “Describe where the pain is and what it feels like.”
C. “Is the pain caused by your diagnosis?”
D. “You probably need surgery.”
, CORRECT ANSWER: B
Rationale:
An open-ended question allows the nurse to obtain important information about the pain's
location, quality, severity, onset, and associated symptoms.
3. Which finding is objective data?
A. “I feel dizzy.”
B. “My pain is severe.”
C. Blood pressure of 168/94 mmHg
D. “I feel nauseated.”
CORRECT ANSWER: C
Rationale:
Objective data are measurable or observable findings. The other options are subjective
symptoms reported by the patient.
4. Which finding should the nurse report promptly?
A. Respiratory rate of 16/min
B. New confusion and difficulty staying awake
C. Pulse of 76/min
D. Normal capillary refill
, CORRECT ANSWER: B
Rationale:
A new change in level of consciousness can indicate hypoxia, infection, metabolic disturbance,
medication effects, or neurological deterioration.
5. Which technique is appropriate when interviewing a patient?
A. Ask several questions simultaneously
B. Use medical terminology whenever possible
C. Begin with open-ended questions
D. Interrupt frequently to save time
CORRECT ANSWER: C
Rationale:
Open-ended questions encourage patients to describe their concerns and symptoms in their
own words.
6. Which assessment finding is most concerning for impaired peripheral circulation?
A. Warm skin and strong pulses
B. Cool extremity with diminished pulse
C. Capillary refill within expected range
D. Symmetrical peripheral pulses
, CORRECT ANSWER: B
Rationale:
Cool skin and diminished pulses may indicate reduced arterial perfusion and require further
assessment.
7. Which finding is most consistent with dehydration?
A. Generalized edema
B. Dry mucous membranes and decreased urine output
C. Jugular venous distention
D. Rapid weight gain
CORRECT ANSWER: B
Rationale:
Dry mucous membranes and reduced urine output are common findings associated with fluid-
volume deficit.
8. Which sequence should the nurse use for an abdominal assessment?
A. Inspection → auscultation → percussion → palpation
B. Palpation → percussion → auscultation → inspection
C. Auscultation → palpation → inspection → percussion
D. Percussion → palpation → inspection → auscultation
2026/2027 | Nightingale College |
GRADED A | Pass Guaranteed - A+
Graded
1. Which action can appropriately be delegated to UAP?
A. Perform the initial nursing assessment
B. Develop the nursing care plan
C. Measure and document routine urinary output
D. Evaluate the patient's response to medication
CORRECT ANSWER: C
Rationale:
Routine measurement of urinary output can generally be delegated when the patient is stable
and the task falls within the UAP's scope. Assessment, care planning, and evaluation remain
nursing responsibilities.
2. A patient reports abdominal pain. What is the nurse's best initial response?
A. “You should take your prescribed medication.”
B. “Describe where the pain is and what it feels like.”
C. “Is the pain caused by your diagnosis?”
D. “You probably need surgery.”
, CORRECT ANSWER: B
Rationale:
An open-ended question allows the nurse to obtain important information about the pain's
location, quality, severity, onset, and associated symptoms.
3. Which finding is objective data?
A. “I feel dizzy.”
B. “My pain is severe.”
C. Blood pressure of 168/94 mmHg
D. “I feel nauseated.”
CORRECT ANSWER: C
Rationale:
Objective data are measurable or observable findings. The other options are subjective
symptoms reported by the patient.
4. Which finding should the nurse report promptly?
A. Respiratory rate of 16/min
B. New confusion and difficulty staying awake
C. Pulse of 76/min
D. Normal capillary refill
, CORRECT ANSWER: B
Rationale:
A new change in level of consciousness can indicate hypoxia, infection, metabolic disturbance,
medication effects, or neurological deterioration.
5. Which technique is appropriate when interviewing a patient?
A. Ask several questions simultaneously
B. Use medical terminology whenever possible
C. Begin with open-ended questions
D. Interrupt frequently to save time
CORRECT ANSWER: C
Rationale:
Open-ended questions encourage patients to describe their concerns and symptoms in their
own words.
6. Which assessment finding is most concerning for impaired peripheral circulation?
A. Warm skin and strong pulses
B. Cool extremity with diminished pulse
C. Capillary refill within expected range
D. Symmetrical peripheral pulses
, CORRECT ANSWER: B
Rationale:
Cool skin and diminished pulses may indicate reduced arterial perfusion and require further
assessment.
7. Which finding is most consistent with dehydration?
A. Generalized edema
B. Dry mucous membranes and decreased urine output
C. Jugular venous distention
D. Rapid weight gain
CORRECT ANSWER: B
Rationale:
Dry mucous membranes and reduced urine output are common findings associated with fluid-
volume deficit.
8. Which sequence should the nurse use for an abdominal assessment?
A. Inspection → auscultation → percussion → palpation
B. Palpation → percussion → auscultation → inspection
C. Auscultation → palpation → inspection → percussion
D. Percussion → palpation → inspection → auscultation
