1
BSN 246 HESI Health Assessment
Remediation (Latest 2025/2026 Update) –
30 Questions and Verified Answers |
100% Correct | Grade A – Nightingale
Question 1
A nurse incorrectly percussed the spleen as tympanic. What is the expected percussion sound
over a healthy spleen?
A. Tympany
B. Resonance
C. Dullness
D. Hyperresonance
Rationale: The spleen, a solid organ, produces a dull percussion sound due to its density.
Tympany indicates air-filled structures (e.g., intestines), resonance is typical over healthy lungs,
and hyperresonance suggests air trapping (e.g., pneumothorax). Correct percussion technique is
critical for organ assessment.
Question 2
A nurse failed to assess for shifting dullness in a client suspected of ascites. What is the correct
technique?
A. Percuss while the client is in Trendelenburg position
B. Percuss supine, then lateral, noting change in dullness
C. Auscultate for fluid sounds in all quadrants
D. Palpate deeply for fluid movement
Rationale: Shifting dullness is assessed by percussing the abdomen in the supine position (noting
dullness from fluid), then repositioning the client laterally to detect a shift to tympany as fluid
moves. Trendelenburg is not used, auscultation does not detect fluid shifts, and palpation tests
for fluid wave, not shifting dullness.
Question 3
A nurse documented a client’s respiratory rate as 14 breaths/min but missed assessing dyspnea
episodes reported in the history. What should the nurse have done?
A. Document the finding as normal
B. Increase the observation time to 2 minutes
, 2
C. Ask the client to describe dyspnea episodes in detail
D. Auscultate lung sounds immediately
Rationale: Dyspnea is a subjective symptom requiring detailed history (onset, triggers, severity)
to guide assessment. A rate of 14 is normal, but ignoring dyspnea misses a critical finding.
Auscultation follows history-taking, and extended observation is unnecessary for a stable rate.
Question 4
A nurse incorrectly assessed anterior-posterior (AP) chest diameter by palpation. What is the
correct technique?
A. Palpation for tenderness
B. Percussion of the chest
C. Observation for barrel chest
D. Auscultation for symmetry
Rationale: AP chest diameter is assessed by observing the chest’s shape (e.g., barrel chest in
COPD). Palpation assesses fremitus or tenderness, percussion evaluates lung density, and
auscultation detects breath sounds, not diameter.
Question 5
A client with bilateral lower lobe atelectasis was percussed incorrectly. What sound should the
nurse expect?
A. Tympany
B. Resonance
C. Dullness
D. Hyperresonance
Rationale: Atelectasis, collapsed lung tissue, produces dullness on percussion due to reduced air
content. Tympany indicates air-filled structures, resonance is normal lung tissue, and
hyperresonance suggests air trapping. Accurate percussion distinguishes pathology.
Question 6
A nurse missed a positive Rovsing’s sign during an abdominal assessment. What indicates a
positive Rovsing’s sign?
A. Pain at McBurney’s point on direct palpation
B. RLQ pain when palpating LLQ
C. Rebound tenderness in RLQ
D. Hypoactive bowel sounds
Rationale: Rovsing’s sign is RLQ pain elicited by LLQ palpation, suggesting appendicitis. Direct
pain at McBurney’s point or rebound tenderness are separate signs, and hypoactive bowel sounds
are non-specific.
Question 7
BSN 246 HESI Health Assessment
Remediation (Latest 2025/2026 Update) –
30 Questions and Verified Answers |
100% Correct | Grade A – Nightingale
Question 1
A nurse incorrectly percussed the spleen as tympanic. What is the expected percussion sound
over a healthy spleen?
A. Tympany
B. Resonance
C. Dullness
D. Hyperresonance
Rationale: The spleen, a solid organ, produces a dull percussion sound due to its density.
Tympany indicates air-filled structures (e.g., intestines), resonance is typical over healthy lungs,
and hyperresonance suggests air trapping (e.g., pneumothorax). Correct percussion technique is
critical for organ assessment.
Question 2
A nurse failed to assess for shifting dullness in a client suspected of ascites. What is the correct
technique?
A. Percuss while the client is in Trendelenburg position
B. Percuss supine, then lateral, noting change in dullness
C. Auscultate for fluid sounds in all quadrants
D. Palpate deeply for fluid movement
Rationale: Shifting dullness is assessed by percussing the abdomen in the supine position (noting
dullness from fluid), then repositioning the client laterally to detect a shift to tympany as fluid
moves. Trendelenburg is not used, auscultation does not detect fluid shifts, and palpation tests
for fluid wave, not shifting dullness.
Question 3
A nurse documented a client’s respiratory rate as 14 breaths/min but missed assessing dyspnea
episodes reported in the history. What should the nurse have done?
A. Document the finding as normal
B. Increase the observation time to 2 minutes
, 2
C. Ask the client to describe dyspnea episodes in detail
D. Auscultate lung sounds immediately
Rationale: Dyspnea is a subjective symptom requiring detailed history (onset, triggers, severity)
to guide assessment. A rate of 14 is normal, but ignoring dyspnea misses a critical finding.
Auscultation follows history-taking, and extended observation is unnecessary for a stable rate.
Question 4
A nurse incorrectly assessed anterior-posterior (AP) chest diameter by palpation. What is the
correct technique?
A. Palpation for tenderness
B. Percussion of the chest
C. Observation for barrel chest
D. Auscultation for symmetry
Rationale: AP chest diameter is assessed by observing the chest’s shape (e.g., barrel chest in
COPD). Palpation assesses fremitus or tenderness, percussion evaluates lung density, and
auscultation detects breath sounds, not diameter.
Question 5
A client with bilateral lower lobe atelectasis was percussed incorrectly. What sound should the
nurse expect?
A. Tympany
B. Resonance
C. Dullness
D. Hyperresonance
Rationale: Atelectasis, collapsed lung tissue, produces dullness on percussion due to reduced air
content. Tympany indicates air-filled structures, resonance is normal lung tissue, and
hyperresonance suggests air trapping. Accurate percussion distinguishes pathology.
Question 6
A nurse missed a positive Rovsing’s sign during an abdominal assessment. What indicates a
positive Rovsing’s sign?
A. Pain at McBurney’s point on direct palpation
B. RLQ pain when palpating LLQ
C. Rebound tenderness in RLQ
D. Hypoactive bowel sounds
Rationale: Rovsing’s sign is RLQ pain elicited by LLQ palpation, suggesting appendicitis. Direct
pain at McBurney’s point or rebound tenderness are separate signs, and hypoactive bowel sounds
are non-specific.
Question 7
