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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
The nurse is interviewing a patient with a hearing impairment. What technique is most beneficial
for effective communication?
A. Determine the patient’s preferred communication method
B. Avoid using facial and hand gestures
C. Request a sign language interpreter before the interview
D. Speak loudly with exaggerated lip movements
Correct Answer: A. Determine the patient’s preferred communication method
Rationale: Asking the patient their preferred communication method (e.g., lip reading, writing,
or signing) ensures effective and respectful interaction. Avoiding gestures may limit
communication, as many patients rely on them. A sign language interpreter may not always be
necessary or preferred, and exaggerated speech can distort lip reading, making it less effective.
Question 2
When selecting an interpreter for a female patient with limited English proficiency, which option
is most appropriate?
A. A male family member
B. A female family member
C. A volunteer college student
D. A trained interpreter
Correct Answer: D. A trained interpreter
Rationale: A trained interpreter ensures accurate, confidential, and culturally sensitive
communication, adhering to healthcare standards. Family members may introduce bias or breach
confidentiality, and untrained volunteers lack the necessary skills for medical interpretation.
Question 3
The nurse is assessing a client with suspected appendicitis. Which finding requires immediate
reporting to the healthcare provider?
, 2
A. Dry mucous membranes
B. Rebound tenderness in the right lower quadrant
C. Dizziness when ambulating
D. Poor skin turgor
Correct Answer: B. Rebound tenderness in the right lower quadrant
Rationale: Rebound tenderness in the right lower quadrant suggests peritoneal inflammation, a
hallmark of acute appendicitis, requiring urgent medical attention. Dry mucous membranes,
dizziness, and poor skin turgor indicate dehydration but are less specific and urgent in this
context.
Question 4
When calculating a digoxin dose of 35 mcg PO for an infant with heart failure (available
concentration: 0.05 mg/mL), how many milliliters should the nurse prepare?
A. 0.5 mL
B. 0.7 mL
C. 1.0 mL
D. 1.2 mL
Correct Answer: B. 0.7 mL
Rationale: Convert 35 mcg to 0.035 mg (1 mg = 1000 mcg). Using the formula Desired
Dose/Available Dose × Volume = 0.035 mg / 0.05 mg × 1 mL = 0.7 mL. Misconceptions arise
from incorrect unit conversion or formula application, leading to errors like 0.5 mL or 1.0 mL.
Question 5
Which laboratory test best identifies the cause of thrombocytopenia by assessing megakaryocyte
numbers?
A. Prothrombin time (PT)
B. Peripheral blood smear
C. 14C serotonin release assay
D. Bone marrow examination
Correct Answer: D. Bone marrow examination
Rationale: Bone marrow examination directly assesses megakaryocyte numbers to determine if
thrombocytopenia results from reduced platelet production (e.g., leukemia). PT evaluates
clotting, peripheral smears assess platelet morphology, and serotonin assays diagnose immune
thrombocytopenia, not megakaryocyte counts.
Question 6
, 3
Where are lymphocytes primarily produced in the body?
A. Spleen
B. Tonsils
C. Bone marrow
D. Thymus gland
Correct Answer: C. Bone marrow
Rationale: Lymphocytes (B and T cells) are produced in the bone marrow. The thymus matures
T cells, while the spleen and tonsils are secondary lymphoid organs for immune response, not
primary production. Misconceptions may arise from confusing production with maturation.
Question 7
During a thoracic assessment of a client with chronic asthma and lung hyperinflation, what
finding is expected?
A. Increased anteroposterior chest diameter
B. Decreased respiratory rate
C. Normal lung percussion
D. Absent breath sounds
Correct Answer: A. Increased anteroposterior chest diameter
Rationale: Chronic asthma causes air trapping, leading to lung hyperinflation and an increased
anteroposterior chest diameter (barrel chest). Respiratory rate may increase, percussion yields
hyperresonance, and breath sounds may be diminished but not absent.
Question 8
The nurse is assessing a client’s cranial nerve function. Which action tests cranial nerve II?
A. Asking the client to stick out their tongue
B. Performing a visual acuity test
C. Testing facial muscle strength
D. Checking pupillary light reflex
Correct Answer: B. Performing a visual acuity test
Rationale: Cranial nerve II (optic nerve) is assessed by testing visual acuity (e.g., Snellen chart).
Pupillary light reflex involves cranial nerves II and III, tongue movement tests cranial nerve XII,
and facial strength tests cranial nerve VII. Misconceptions occur when confusing related
functions.
Question 9
When assessing a client’s skin turgor, where should the nurse pinch the skin?
A. Forearm
BSN 246 HESI Health Assessment Exam
V3 (Latest 2025/2026 Update) Questions
and Verified Answers | 100% Correct |
Grade A – Nightingale
Question 1
The nurse is interviewing a patient with a hearing impairment. What technique is most beneficial
for effective communication?
A. Determine the patient’s preferred communication method
B. Avoid using facial and hand gestures
C. Request a sign language interpreter before the interview
D. Speak loudly with exaggerated lip movements
Correct Answer: A. Determine the patient’s preferred communication method
Rationale: Asking the patient their preferred communication method (e.g., lip reading, writing,
or signing) ensures effective and respectful interaction. Avoiding gestures may limit
communication, as many patients rely on them. A sign language interpreter may not always be
necessary or preferred, and exaggerated speech can distort lip reading, making it less effective.
Question 2
When selecting an interpreter for a female patient with limited English proficiency, which option
is most appropriate?
A. A male family member
B. A female family member
C. A volunteer college student
D. A trained interpreter
Correct Answer: D. A trained interpreter
Rationale: A trained interpreter ensures accurate, confidential, and culturally sensitive
communication, adhering to healthcare standards. Family members may introduce bias or breach
confidentiality, and untrained volunteers lack the necessary skills for medical interpretation.
Question 3
The nurse is assessing a client with suspected appendicitis. Which finding requires immediate
reporting to the healthcare provider?
, 2
A. Dry mucous membranes
B. Rebound tenderness in the right lower quadrant
C. Dizziness when ambulating
D. Poor skin turgor
Correct Answer: B. Rebound tenderness in the right lower quadrant
Rationale: Rebound tenderness in the right lower quadrant suggests peritoneal inflammation, a
hallmark of acute appendicitis, requiring urgent medical attention. Dry mucous membranes,
dizziness, and poor skin turgor indicate dehydration but are less specific and urgent in this
context.
Question 4
When calculating a digoxin dose of 35 mcg PO for an infant with heart failure (available
concentration: 0.05 mg/mL), how many milliliters should the nurse prepare?
A. 0.5 mL
B. 0.7 mL
C. 1.0 mL
D. 1.2 mL
Correct Answer: B. 0.7 mL
Rationale: Convert 35 mcg to 0.035 mg (1 mg = 1000 mcg). Using the formula Desired
Dose/Available Dose × Volume = 0.035 mg / 0.05 mg × 1 mL = 0.7 mL. Misconceptions arise
from incorrect unit conversion or formula application, leading to errors like 0.5 mL or 1.0 mL.
Question 5
Which laboratory test best identifies the cause of thrombocytopenia by assessing megakaryocyte
numbers?
A. Prothrombin time (PT)
B. Peripheral blood smear
C. 14C serotonin release assay
D. Bone marrow examination
Correct Answer: D. Bone marrow examination
Rationale: Bone marrow examination directly assesses megakaryocyte numbers to determine if
thrombocytopenia results from reduced platelet production (e.g., leukemia). PT evaluates
clotting, peripheral smears assess platelet morphology, and serotonin assays diagnose immune
thrombocytopenia, not megakaryocyte counts.
Question 6
, 3
Where are lymphocytes primarily produced in the body?
A. Spleen
B. Tonsils
C. Bone marrow
D. Thymus gland
Correct Answer: C. Bone marrow
Rationale: Lymphocytes (B and T cells) are produced in the bone marrow. The thymus matures
T cells, while the spleen and tonsils are secondary lymphoid organs for immune response, not
primary production. Misconceptions may arise from confusing production with maturation.
Question 7
During a thoracic assessment of a client with chronic asthma and lung hyperinflation, what
finding is expected?
A. Increased anteroposterior chest diameter
B. Decreased respiratory rate
C. Normal lung percussion
D. Absent breath sounds
Correct Answer: A. Increased anteroposterior chest diameter
Rationale: Chronic asthma causes air trapping, leading to lung hyperinflation and an increased
anteroposterior chest diameter (barrel chest). Respiratory rate may increase, percussion yields
hyperresonance, and breath sounds may be diminished but not absent.
Question 8
The nurse is assessing a client’s cranial nerve function. Which action tests cranial nerve II?
A. Asking the client to stick out their tongue
B. Performing a visual acuity test
C. Testing facial muscle strength
D. Checking pupillary light reflex
Correct Answer: B. Performing a visual acuity test
Rationale: Cranial nerve II (optic nerve) is assessed by testing visual acuity (e.g., Snellen chart).
Pupillary light reflex involves cranial nerves II and III, tongue movement tests cranial nerve XII,
and facial strength tests cranial nerve VII. Misconceptions occur when confusing related
functions.
Question 9
When assessing a client’s skin turgor, where should the nurse pinch the skin?
A. Forearm
