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BSN 246 HESI Health Assessment Exam V3 (Latest
2025/2026 Update) Questions and Verified Answers |
100% Correct | Grade A – Nightingale
Question 1
A nurse is assessing a client who reports chest pain. Which initial action should the nurse take to
evaluate the pain?
A) Administer oxygen at 2 L/min via nasal cannula.
B) Obtain a 12-lead electrocardiogram (ECG).
C) Ask the client to describe the pain’s onset, duration, and characteristics.
D) Check the client’s blood pressure and pulse rate.
Correct Answer: C
Rationale: The initial step in assessing chest pain is to gather a detailed history of the pain’s
onset, duration, location, intensity, and characteristics (e.g., sharp, dull, radiating). This helps
differentiate potential causes, such as cardiac, musculoskeletal, or gastrointestinal issues.
Administering oxygen (A) or obtaining an ECG (B) may be appropriate but only after gathering
subjective data to guide further actions. Checking vital signs (D) is important but secondary to
understanding the pain’s nature. Common Misconception: Some may prioritize immediate
interventions like oxygen or ECG, but without a pain history, these actions lack context and may
delay accurate diagnosis.
Question 2
During a respiratory assessment, the nurse notes a client’s respiratory rate is 22 breaths/minute
with shallow breathing. What is the best nursing action?
A) Encourage the client to take slow, deep breaths.
B) Auscultate the lung fields for adventitious sounds.
C) Check the client’s oxygen saturation immediately.
D) Document the findings as normal and continue the assessment.
Correct Answer: B
Rationale: A respiratory rate of 22 breaths/minute with shallow breathing suggests tachypnea,
which may indicate an underlying issue such as hypoxia or infection. Auscultating the lung fields
for adventitious sounds (e.g., crackles, wheezes) provides objective data to identify potential
respiratory abnormalities. Encouraging deep breathing (A) may be therapeutic but does not
assess the cause. Checking oxygen saturation (C) is relevant but follows auscultation to confirm
findings. Documenting as normal (D) is incorrect, as the rate and pattern are abnormal. Common
, 2
Misconception: Students may assume a slightly elevated respiratory rate is normal, but shallow
breathing warrants further investigation.
Question 3
A nurse is performing a cranial nerve assessment and tests cranial nerve II. Which action should
the nurse take?
A) Ask the client to differentiate between sweet and salty tastes.
B) Use a Snellen chart to assess visual acuity.
C) Observe the client’s ability to shrug their shoulders.
D) Test the client’s pupil response to light.
Correct Answer: B
Rationale: Cranial nerve II (optic nerve) is responsible for vision. Using a Snellen chart to assess
visual acuity is the most direct method to evaluate its function. Testing taste (A) assesses cranial
nerves VII and IX. Shoulder shrugging (C) tests cranial nerve XI (spinal accessory). Pupil
response to light (D) involves cranial nerve III (oculomotor), not II. Common Misconception:
Confusing cranial nerve functions, especially mistaking pupil response (III) for visual acuity (II),
is common among students.
Question 4
A client reports swelling in their lower extremities. Which assessment finding supports this
complaint?
A) Warm, dry skin over the ankles.
B) 2+ pitting edema bilaterally in the ankles.
C) Strong, equal pedal pulses.
D) Absence of hair on the lower legs.
Correct Answer: B
Rationale: Pitting edema, graded as 2+ (moderate indentation), directly confirms the client’s
report of swelling, indicating fluid accumulation in the tissues. Warm, dry skin (A) does not
indicate swelling and may suggest normal circulation. Strong pulses (C) assess vascular status
but not edema. Hair loss (D) may indicate chronic arterial insufficiency, not swelling. Common
Misconception: Students may confuse edema with other findings like hair loss or pulse strength,
but only pitting edema directly correlates with swelling.
Question 5
When assessing a client’s abdomen, the nurse notes high-pitched, frequent bowel sounds. What
condition might this finding suggest?
BSN 246 HESI Health Assessment Exam V3 (Latest
2025/2026 Update) Questions and Verified Answers |
100% Correct | Grade A – Nightingale
Question 1
A nurse is assessing a client who reports chest pain. Which initial action should the nurse take to
evaluate the pain?
A) Administer oxygen at 2 L/min via nasal cannula.
B) Obtain a 12-lead electrocardiogram (ECG).
C) Ask the client to describe the pain’s onset, duration, and characteristics.
D) Check the client’s blood pressure and pulse rate.
Correct Answer: C
Rationale: The initial step in assessing chest pain is to gather a detailed history of the pain’s
onset, duration, location, intensity, and characteristics (e.g., sharp, dull, radiating). This helps
differentiate potential causes, such as cardiac, musculoskeletal, or gastrointestinal issues.
Administering oxygen (A) or obtaining an ECG (B) may be appropriate but only after gathering
subjective data to guide further actions. Checking vital signs (D) is important but secondary to
understanding the pain’s nature. Common Misconception: Some may prioritize immediate
interventions like oxygen or ECG, but without a pain history, these actions lack context and may
delay accurate diagnosis.
Question 2
During a respiratory assessment, the nurse notes a client’s respiratory rate is 22 breaths/minute
with shallow breathing. What is the best nursing action?
A) Encourage the client to take slow, deep breaths.
B) Auscultate the lung fields for adventitious sounds.
C) Check the client’s oxygen saturation immediately.
D) Document the findings as normal and continue the assessment.
Correct Answer: B
Rationale: A respiratory rate of 22 breaths/minute with shallow breathing suggests tachypnea,
which may indicate an underlying issue such as hypoxia or infection. Auscultating the lung fields
for adventitious sounds (e.g., crackles, wheezes) provides objective data to identify potential
respiratory abnormalities. Encouraging deep breathing (A) may be therapeutic but does not
assess the cause. Checking oxygen saturation (C) is relevant but follows auscultation to confirm
findings. Documenting as normal (D) is incorrect, as the rate and pattern are abnormal. Common
, 2
Misconception: Students may assume a slightly elevated respiratory rate is normal, but shallow
breathing warrants further investigation.
Question 3
A nurse is performing a cranial nerve assessment and tests cranial nerve II. Which action should
the nurse take?
A) Ask the client to differentiate between sweet and salty tastes.
B) Use a Snellen chart to assess visual acuity.
C) Observe the client’s ability to shrug their shoulders.
D) Test the client’s pupil response to light.
Correct Answer: B
Rationale: Cranial nerve II (optic nerve) is responsible for vision. Using a Snellen chart to assess
visual acuity is the most direct method to evaluate its function. Testing taste (A) assesses cranial
nerves VII and IX. Shoulder shrugging (C) tests cranial nerve XI (spinal accessory). Pupil
response to light (D) involves cranial nerve III (oculomotor), not II. Common Misconception:
Confusing cranial nerve functions, especially mistaking pupil response (III) for visual acuity (II),
is common among students.
Question 4
A client reports swelling in their lower extremities. Which assessment finding supports this
complaint?
A) Warm, dry skin over the ankles.
B) 2+ pitting edema bilaterally in the ankles.
C) Strong, equal pedal pulses.
D) Absence of hair on the lower legs.
Correct Answer: B
Rationale: Pitting edema, graded as 2+ (moderate indentation), directly confirms the client’s
report of swelling, indicating fluid accumulation in the tissues. Warm, dry skin (A) does not
indicate swelling and may suggest normal circulation. Strong pulses (C) assess vascular status
but not edema. Hair loss (D) may indicate chronic arterial insufficiency, not swelling. Common
Misconception: Students may confuse edema with other findings like hair loss or pulse strength,
but only pitting edema directly correlates with swelling.
Question 5
When assessing a client’s abdomen, the nurse notes high-pitched, frequent bowel sounds. What
condition might this finding suggest?
