NURl 101/l NUR101l HESI:l (Latestl 2025/l
2026l Update)l Healthl Assessmentl Review|l
Qsl &l As|l Gradel A|l 100%l Correctl
(Verifiedl Answers)-l Fortis
QUESTION
Thel nursel isl assessingl al client'sl middlel lungl lobe.l Whichl isl thel bestl locationl forl thel
nursel tol placel al stethoscopel diaphragml tol hearl normall lungl soundsl inl thisl lobe?
4thl intercostall space,l rightl midclavicularl line.
5thl intercostall space,l leftl midclavicularl line.
Leftl mid-posteriorl lungl field.
Rightl mid-posteriorl lungl field.
Answer:l
4thl intercostall space,l rightl midclavicularl line.
Thel 4thl intercostall space,l thel rightl midclavicularl linel isl thel bestl locationl forl thel nursel
tol placel al stethoscopel diaphragml tol hearl lungl soundsl inl thel client'sl middlel lobe.l Thel
leftl sidel hasl onlyl twol lobesl (upperl andl lower)l andl middlel lobel soundsl cannotl normallyl
bel heardl inl thel posteriorl lungl fields.
QUESTION
Al clientl isl inl thel clinicall forl al yearlyl physicall examination.l Whichl actionl shouldl thel
nursel takel whenl preparingl tol examinel thel client'sl abdomen?
Keepl thel rooml cooll sol thel clientl isl notl perspiring.
Askl thel clientl tol urinatel beforel beginningl thel examination.
Examinel painfull orl tenderl areasl first.
Positionl thel clientl supinel withl armsl overl thel head.
Answer:l
Askl thel clientl tol urinatel beforel beginningl thel examination.
Anl emptyl bladderl aidsl inl abdominall walll relaxation.l Thel nursel shouldl askl thel clientl tol
emptyl thel bladderl beforel examiningl thel abdomen.
,QUESTION
Thel nursel examinesl thel skinl ofl anl olderl adultl client.l Whichl skinl variationl isl
consideredl al normall findingl forl al clientl inl thisl agel group?
Dryness.
Lentigines.
Bruising.
Tenting.
Answer:l
Lentigines.
Lentiginesl orl commonlyl referredl tol asl liverl spotsl arel irregularlyl shapedl darkl spotsl onl
thel skinl causedl byl agingl andl extensivel sunl exposure.l Thisl skinl variationl isl al normall
findingl inl anl olderl adultl client.
QUESTION
Whilel performingl al head-to-toel assessment,l thel nursel assessesl thel client'sl pupillaryl
accommodation.l Duringl thel secondl portionl ofl thel test,l thel nursel notesl thatl thel client'sl
pupilsl constrictl andl therel isl al convergencel ofl thel axesl ofl thel eyes.l Whatl actionl shouldl
thel nursel implementl next?
Documentl al normall finding.
Requestl al referrall tol anl opthamologist.
Repeatl thel testl afterl havingl thel clientl restl forl 5l minutes.
Askl thel client,l "Havel youl noticedl thatl youl cannotl seel thingsl closel up?"
Answer:l
Documentl al normall finding.
Whenl testingl forl pupillaryl accommodation,l thel nursel asksl thel clientl tol focusl onl al
distantl objectl andl thenl shiftl thel gazel tol al penlightl tipl nearl thel nose.l Focusingl onl al
distantl objectl causesl bothl pupilsl tol dilate;l shiftingl thel gazel tol al nearl objectl (al fingerl
orl al penlightl tip),l whichl isl heldl aboutl 7l tol 8l cml (3l inches)l froml thel client'sl nose,l
shouldl resultl inl bilaterall pupillaryl constrictionl withl bothl eyesl focusedl onl thel objectl
simultaneously.
QUESTION
,Afterl completingl thel initiall generall assessment,l thel nursel isl nowl completingl al focusedl
abdominall assessmentl ofl al clientl whol wasl admittedl forl abdominall pain.l Whichl
assessmentl isl mostl importantl forl thel nursel tol implement?
Inspectl forl abdominall distensionl thenl percussl forl tympany.
Palpatel thel abdomenl afterl auscultatingl forl bowell sounds.
Measurel thel client'sl oxygenl saturation.
Askl ifl painl medicationl wasl taken.
Answer:l
Palpatel thel abdomenl afterl auscultatingl forl bowell sounds.
Duringl al focusedl assessmentl ofl thel abdomen,l thel nursel shouldl palpatel forl abdominall
tensionl andl tendernessl afterl auscultatingl forl bowell sounds,l whichl canl bel alteredl byl
palpationl andl percussion.l Thel abdominall assessmentl shouldl progressl inl thel sequencel ofl
inspection,l auscultation,l palpation,l andl thenl percussion.
QUESTION
Whenl teachingl al clientl howl tol performl al monthlyl breastl self-assessment,l thel nursel
shouldl telll thel clientl thatl itl isl mostl importantl tol assessl whichl partl ofl thel breastl morel
closelyl forl changes?
Upperl outerl quadrant.
Lowerl innerl quadrant.
Upperl innerl quadrant.
Lowerl outerl quadrant.
Answer:l
Upperl outerl quadrant.
Althoughl thel clientl shouldl bel instructedl tol performl al thoroughl breastl self-assessmentl
everyl monthl tol checkl forl tissuel changes,l evidencel hasl shownl thatl thel upperl outerl
quadrantl isl thel sitel ofl mostl breastl tumors.
QUESTION
Al clientl reportsl al recentl onsetl ofl nauseal andl vomiting.l Whatl subjectivel informationl isl
importantl forl thel nursel tol ascertain?
Askl howl muchl weightl thel clientl gainedl onl vacation.
Askl whetherl thel clientl hasl beenl inl al foreignl countryl recently.
, Observel thel symmetryl ofl thel abdomen.
Countl thel bowell soundsl inl eachl abdominall quadrant.
Answer:l
Askl whetherl thel clientl hasl beenl inl al foreignl countryl recently.
GIl upsetl andl diarrheal occurl whenl exposedl tol newl locall pathogensl inl developingl
countries.l Thel waterl supplyl mayl bel contaminated.
QUESTION
Thel nursel isl conductingl al familyl historyl asl partl ofl thel assessmentl interview.l Whichl
actionl shouldl thel nursel takel tol ensurel thatl sufficientl informationl aboutl thel client'sl
bloodl relativesl isl obtained?
Documentl atl leastl 3l generationsl ofl thel client'sl familyl medicall historyl ifl possible.
Askl aboutl anyl geneticl conditionsl thatl mayl bel presentl inl thel family.
Instructl thel clientl tol developl al genograml tol bringl tol thel nextl visit.
Requestl medicall recordsl ofl alll thel client'sl immediatel familyl members.
Answer:l
Documentl atl leastl 3l generationsl ofl thel client'sl familyl medicall historyl ifl possible.
Thel familyl historyl assistsl thel healthcarel providerl inl determiningl thel client'sl healthl
risks.l Itl isl recommendedl thatl familyl medicall historyl bel tracedl backl threel generationsl ifl
possible.l Thesel generationsl consistsl ofl thel client'sl blood-relativesl ofl anyl siblings,l
parents,l andl maternall andl paternall grandparents.
QUESTION
Thel nursel isl conductingl anl interviewl withl al clientl whol speaksl limitedl English.l Whichl
actionl shouldl thel nursel implement?
Seekl thel assistancel ofl al healthcarel teaml memberl whol speaksl thel client'sl preferredl
language.
Continuel withl thel client'sl assessmentl interviewl usingl simplel Englishl words.
Havel thel clientl reschedulel forl al timel whenl al familyl memberl canl bel therel tol interpret.
Askl thel clientl tol calll al friendl whol speaksl Englishl andl isl ablel tol interpret.
Answer:l
Seekl thel assistancel ofl al healthcarel teaml memberl whol speaksl thel client'sl preferredl
language.
2026l Update)l Healthl Assessmentl Review|l
Qsl &l As|l Gradel A|l 100%l Correctl
(Verifiedl Answers)-l Fortis
QUESTION
Thel nursel isl assessingl al client'sl middlel lungl lobe.l Whichl isl thel bestl locationl forl thel
nursel tol placel al stethoscopel diaphragml tol hearl normall lungl soundsl inl thisl lobe?
4thl intercostall space,l rightl midclavicularl line.
5thl intercostall space,l leftl midclavicularl line.
Leftl mid-posteriorl lungl field.
Rightl mid-posteriorl lungl field.
Answer:l
4thl intercostall space,l rightl midclavicularl line.
Thel 4thl intercostall space,l thel rightl midclavicularl linel isl thel bestl locationl forl thel nursel
tol placel al stethoscopel diaphragml tol hearl lungl soundsl inl thel client'sl middlel lobe.l Thel
leftl sidel hasl onlyl twol lobesl (upperl andl lower)l andl middlel lobel soundsl cannotl normallyl
bel heardl inl thel posteriorl lungl fields.
QUESTION
Al clientl isl inl thel clinicall forl al yearlyl physicall examination.l Whichl actionl shouldl thel
nursel takel whenl preparingl tol examinel thel client'sl abdomen?
Keepl thel rooml cooll sol thel clientl isl notl perspiring.
Askl thel clientl tol urinatel beforel beginningl thel examination.
Examinel painfull orl tenderl areasl first.
Positionl thel clientl supinel withl armsl overl thel head.
Answer:l
Askl thel clientl tol urinatel beforel beginningl thel examination.
Anl emptyl bladderl aidsl inl abdominall walll relaxation.l Thel nursel shouldl askl thel clientl tol
emptyl thel bladderl beforel examiningl thel abdomen.
,QUESTION
Thel nursel examinesl thel skinl ofl anl olderl adultl client.l Whichl skinl variationl isl
consideredl al normall findingl forl al clientl inl thisl agel group?
Dryness.
Lentigines.
Bruising.
Tenting.
Answer:l
Lentigines.
Lentiginesl orl commonlyl referredl tol asl liverl spotsl arel irregularlyl shapedl darkl spotsl onl
thel skinl causedl byl agingl andl extensivel sunl exposure.l Thisl skinl variationl isl al normall
findingl inl anl olderl adultl client.
QUESTION
Whilel performingl al head-to-toel assessment,l thel nursel assessesl thel client'sl pupillaryl
accommodation.l Duringl thel secondl portionl ofl thel test,l thel nursel notesl thatl thel client'sl
pupilsl constrictl andl therel isl al convergencel ofl thel axesl ofl thel eyes.l Whatl actionl shouldl
thel nursel implementl next?
Documentl al normall finding.
Requestl al referrall tol anl opthamologist.
Repeatl thel testl afterl havingl thel clientl restl forl 5l minutes.
Askl thel client,l "Havel youl noticedl thatl youl cannotl seel thingsl closel up?"
Answer:l
Documentl al normall finding.
Whenl testingl forl pupillaryl accommodation,l thel nursel asksl thel clientl tol focusl onl al
distantl objectl andl thenl shiftl thel gazel tol al penlightl tipl nearl thel nose.l Focusingl onl al
distantl objectl causesl bothl pupilsl tol dilate;l shiftingl thel gazel tol al nearl objectl (al fingerl
orl al penlightl tip),l whichl isl heldl aboutl 7l tol 8l cml (3l inches)l froml thel client'sl nose,l
shouldl resultl inl bilaterall pupillaryl constrictionl withl bothl eyesl focusedl onl thel objectl
simultaneously.
QUESTION
,Afterl completingl thel initiall generall assessment,l thel nursel isl nowl completingl al focusedl
abdominall assessmentl ofl al clientl whol wasl admittedl forl abdominall pain.l Whichl
assessmentl isl mostl importantl forl thel nursel tol implement?
Inspectl forl abdominall distensionl thenl percussl forl tympany.
Palpatel thel abdomenl afterl auscultatingl forl bowell sounds.
Measurel thel client'sl oxygenl saturation.
Askl ifl painl medicationl wasl taken.
Answer:l
Palpatel thel abdomenl afterl auscultatingl forl bowell sounds.
Duringl al focusedl assessmentl ofl thel abdomen,l thel nursel shouldl palpatel forl abdominall
tensionl andl tendernessl afterl auscultatingl forl bowell sounds,l whichl canl bel alteredl byl
palpationl andl percussion.l Thel abdominall assessmentl shouldl progressl inl thel sequencel ofl
inspection,l auscultation,l palpation,l andl thenl percussion.
QUESTION
Whenl teachingl al clientl howl tol performl al monthlyl breastl self-assessment,l thel nursel
shouldl telll thel clientl thatl itl isl mostl importantl tol assessl whichl partl ofl thel breastl morel
closelyl forl changes?
Upperl outerl quadrant.
Lowerl innerl quadrant.
Upperl innerl quadrant.
Lowerl outerl quadrant.
Answer:l
Upperl outerl quadrant.
Althoughl thel clientl shouldl bel instructedl tol performl al thoroughl breastl self-assessmentl
everyl monthl tol checkl forl tissuel changes,l evidencel hasl shownl thatl thel upperl outerl
quadrantl isl thel sitel ofl mostl breastl tumors.
QUESTION
Al clientl reportsl al recentl onsetl ofl nauseal andl vomiting.l Whatl subjectivel informationl isl
importantl forl thel nursel tol ascertain?
Askl howl muchl weightl thel clientl gainedl onl vacation.
Askl whetherl thel clientl hasl beenl inl al foreignl countryl recently.
, Observel thel symmetryl ofl thel abdomen.
Countl thel bowell soundsl inl eachl abdominall quadrant.
Answer:l
Askl whetherl thel clientl hasl beenl inl al foreignl countryl recently.
GIl upsetl andl diarrheal occurl whenl exposedl tol newl locall pathogensl inl developingl
countries.l Thel waterl supplyl mayl bel contaminated.
QUESTION
Thel nursel isl conductingl al familyl historyl asl partl ofl thel assessmentl interview.l Whichl
actionl shouldl thel nursel takel tol ensurel thatl sufficientl informationl aboutl thel client'sl
bloodl relativesl isl obtained?
Documentl atl leastl 3l generationsl ofl thel client'sl familyl medicall historyl ifl possible.
Askl aboutl anyl geneticl conditionsl thatl mayl bel presentl inl thel family.
Instructl thel clientl tol developl al genograml tol bringl tol thel nextl visit.
Requestl medicall recordsl ofl alll thel client'sl immediatel familyl members.
Answer:l
Documentl atl leastl 3l generationsl ofl thel client'sl familyl medicall historyl ifl possible.
Thel familyl historyl assistsl thel healthcarel providerl inl determiningl thel client'sl healthl
risks.l Itl isl recommendedl thatl familyl medicall historyl bel tracedl backl threel generationsl ifl
possible.l Thesel generationsl consistsl ofl thel client'sl blood-relativesl ofl anyl siblings,l
parents,l andl maternall andl paternall grandparents.
QUESTION
Thel nursel isl conductingl anl interviewl withl al clientl whol speaksl limitedl English.l Whichl
actionl shouldl thel nursel implement?
Seekl thel assistancel ofl al healthcarel teaml memberl whol speaksl thel client'sl preferredl
language.
Continuel withl thel client'sl assessmentl interviewl usingl simplel Englishl words.
Havel thel clientl reschedulel forl al timel whenl al familyl memberl canl bel therel tol interpret.
Askl thel clientl tol calll al friendl whol speaksl Englishl andl isl ablel tol interpret.
Answer:l
Seekl thel assistancel ofl al healthcarel teaml memberl whol speaksl thel client'sl preferredl
language.
