University of Pennsylvania of nursing HESI V2
Health Assessment Exam 2025: 100
Comprehensive Practice Questions, Rationales,
and Study Guide for Nursing Students
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for
evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the
registered nurse (RN) anticipate to be elevated if the client experienced myocardial
damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia modified albumin. - - correct ans- -Serum troponin.
Troponin is the most sensitive and specific test for myocardial damage. Troponin
elevation is more specific than CK-MB.
The registered nurse (RN) is developing the plan of care for a client who is admitted for
alcohol detoxification. Which goal should be most important for the RN to primarily
focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization. - - correct ans- -The client will
remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and sensory disturbances
as well as delirium tremors during withdrawal. Remaining free from injury is the most
important goal for the acute phase of alcohol withdrawal.
,The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized
for weight loss and generalized weakness. Laboratory values show a white blood count
(WBC) of 2,500/mm3 and a platelet countof 160,000/mm3. Which intervention is the
primary focus in the client's plan of care for the RN to implement?
Assist with frequent ambulation.
Encourage visitors to visit.
Maintain strict protective precautions.
Avoid peripheral injections. - - correct ans- -Maintain strict protective precautions.
Rationale
The client should be under strict protective transmission precautions because the WBC
values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an
increased high risk for infection.
The registered nurse (RN) assesses a client's results for arterial blood gases who has
emphysema. Which finding is consistent with respiratory acidosis?
pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L.
pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L.
pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L.
pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L. - - correct ans- -pH 7.32, pCO2 46 mmHg,
HCO3 24 MEq/L.
Rationale
Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L,
and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L
represents a client with respiratory acidosis which is characterized by: low pH,
pCO2higher than normal, and HCO3 within normal limits.
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The
healthcare provider recently changed the medication to enalaprilto manage the client's
blood pressure. Which instruction should the RN provide the client regarding the new
medication?
Take the medication at bedtime.
Report presence of increased bruising.
,Check pulse before taking medication.
Rise slowly when getting out of bed or chair. - - correct ans- -Rise slowly when getting
out of bed or chair.
Rationale
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which
has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a
sitting or lying down position is important to teach the client to avoid dizziness and
potentially falling.
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 therapeutic response should
the RN anticipate?
Reduced pain and minimized brusing.
Lowering of body core temperature.
Increased circulation around injury.
Reabsorption of edema at injury. - - correct ans- -Reduced pain and minimized brusing.
Rationale
Cold applications produce a topical anesthetic effect to reduce pain as well as
constricts blood vessels to minimize bruising.
Which action should the registered nurse (RN) implement to complete an assessment
for a client while using an interpreter?
Ask closed-ended questions with the assistance of the interpreter.
Maintain eye contact with the client while listening to the translation.
Instruct interpreter to answer questions from interpreter's point of view.
Protect the client's privacy by asking a limited number of questions. - - correct ans- -
Maintain eye contact with the client while listening to the translation.
Rationale
When completing an assessment, the RN should maintain eye contact with the client to
gather additional information from the client's nonverbal cues.
, The registered nurse (RN) is assessing common complications related to a client's
recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN
instruct the client to report immediately?
Fever related to infection.
Weight loss and anorexia.
Depressed mood.
Break in tissue integrity. - - correct ans- -Fever related to infection.
Rationale
Secondary infections are a major concern with SLE clients due to the use of
corticosteroids and chemotherapeutic agents, which suppresses the immune system,
so reporting fever and infections should be reported immediately.
An older client is admitted to the hospital with severe diarrhea. The registered nurse
(RN) is completing an assessment and notes the client has dry mucous membranes
and poor skin turgor. Which assessment data should the RN gather to determine if the
client has a fluid volume deficit?
Lower extremity edema.
Orthostatic hypotension.
Elevated blood pressure.
Cheyne-Stokes respirations. - - correct ans- -Orthostatic hypotension.
Rationale
Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has
experienced severe diarrhea.
The registered nurse (RN) is caring for an older client who recently experienced a
fractured pelvis from a fall. Which assessment finding is most important for the RN to
report the healthcare provider?
Lower back pain.
Headache of 7 on scale 1 to 10.
Blood pressure of 140/98.
Dyspneal. - - correct ans- -Dyspneal.
Health Assessment Exam 2025: 100
Comprehensive Practice Questions, Rationales,
and Study Guide for Nursing Students
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for
evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the
registered nurse (RN) anticipate to be elevated if the client experienced myocardial
damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia modified albumin. - - correct ans- -Serum troponin.
Troponin is the most sensitive and specific test for myocardial damage. Troponin
elevation is more specific than CK-MB.
The registered nurse (RN) is developing the plan of care for a client who is admitted for
alcohol detoxification. Which goal should be most important for the RN to primarily
focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization. - - correct ans- -The client will
remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and sensory disturbances
as well as delirium tremors during withdrawal. Remaining free from injury is the most
important goal for the acute phase of alcohol withdrawal.
,The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized
for weight loss and generalized weakness. Laboratory values show a white blood count
(WBC) of 2,500/mm3 and a platelet countof 160,000/mm3. Which intervention is the
primary focus in the client's plan of care for the RN to implement?
Assist with frequent ambulation.
Encourage visitors to visit.
Maintain strict protective precautions.
Avoid peripheral injections. - - correct ans- -Maintain strict protective precautions.
Rationale
The client should be under strict protective transmission precautions because the WBC
values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an
increased high risk for infection.
The registered nurse (RN) assesses a client's results for arterial blood gases who has
emphysema. Which finding is consistent with respiratory acidosis?
pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L.
pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L.
pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L.
pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L. - - correct ans- -pH 7.32, pCO2 46 mmHg,
HCO3 24 MEq/L.
Rationale
Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L,
and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L
represents a client with respiratory acidosis which is characterized by: low pH,
pCO2higher than normal, and HCO3 within normal limits.
The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The
healthcare provider recently changed the medication to enalaprilto manage the client's
blood pressure. Which instruction should the RN provide the client regarding the new
medication?
Take the medication at bedtime.
Report presence of increased bruising.
,Check pulse before taking medication.
Rise slowly when getting out of bed or chair. - - correct ans- -Rise slowly when getting
out of bed or chair.
Rationale
The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which
has the side effect oforthostatic hypotension. Instructing the client to rise slowly from a
sitting or lying down position is important to teach the client to avoid dizziness and
potentially falling.
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 therapeutic response should
the RN anticipate?
Reduced pain and minimized brusing.
Lowering of body core temperature.
Increased circulation around injury.
Reabsorption of edema at injury. - - correct ans- -Reduced pain and minimized brusing.
Rationale
Cold applications produce a topical anesthetic effect to reduce pain as well as
constricts blood vessels to minimize bruising.
Which action should the registered nurse (RN) implement to complete an assessment
for a client while using an interpreter?
Ask closed-ended questions with the assistance of the interpreter.
Maintain eye contact with the client while listening to the translation.
Instruct interpreter to answer questions from interpreter's point of view.
Protect the client's privacy by asking a limited number of questions. - - correct ans- -
Maintain eye contact with the client while listening to the translation.
Rationale
When completing an assessment, the RN should maintain eye contact with the client to
gather additional information from the client's nonverbal cues.
, The registered nurse (RN) is assessing common complications related to a client's
recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN
instruct the client to report immediately?
Fever related to infection.
Weight loss and anorexia.
Depressed mood.
Break in tissue integrity. - - correct ans- -Fever related to infection.
Rationale
Secondary infections are a major concern with SLE clients due to the use of
corticosteroids and chemotherapeutic agents, which suppresses the immune system,
so reporting fever and infections should be reported immediately.
An older client is admitted to the hospital with severe diarrhea. The registered nurse
(RN) is completing an assessment and notes the client has dry mucous membranes
and poor skin turgor. Which assessment data should the RN gather to determine if the
client has a fluid volume deficit?
Lower extremity edema.
Orthostatic hypotension.
Elevated blood pressure.
Cheyne-Stokes respirations. - - correct ans- -Orthostatic hypotension.
Rationale
Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has
experienced severe diarrhea.
The registered nurse (RN) is caring for an older client who recently experienced a
fractured pelvis from a fall. Which assessment finding is most important for the RN to
report the healthcare provider?
Lower back pain.
Headache of 7 on scale 1 to 10.
Blood pressure of 140/98.
Dyspneal. - - correct ans- -Dyspneal.
