BSN 246 – HESI Health Assessment (V1) |
Actual Exam 2026/2027 Review
Nightingale College – Comprehensive
Preparation Guide with Detailed
Rationales & Key Nursing Concepts
The nurse is performing a thoracic assessment on a client with chronic asthma
and hyperinflation of the lungs. Which finding should be expected for this client?
Barrel chest.
Rationale: Chronic air trapping and hyperinflation (as in long-standing asthma or
COPD) cause increased anterior-posterior chest diameter, producing a barrel-
shaped chest.
The nurse is assessing bowel sounds for a hospitalized client. The nurse has
heard bowel sounds in the right upper quadrant. What action should the nurse take
next?
Note the character and frequency of bowel sounds.
Rationale: After detecting bowel sounds, you document their quality and
frequency (normal, hypoactive, hyperactive, borborygmi) rather than just location.
During inspection of a client's mouth and pharynx, the nurse places a tongue
blade on the back of the tongue which causes the client to gag. After removing the
tongue blade, what action should the nurse take?
Document an intact gag reflex.
Rationale: A gag response on stimulation of the posterior pharynx indicates the
glossopharyngeal and vagus reflexes are intact; this is appropriate to record.
When teaching a client how to perform a monthly breast self-assessment, the
nurse should tell the client that it is most important to assess which part of the
breast more closely for changes?
Upper outer quadrant.
,Rationale: The upper outer quadrant contains the greatest proportion of breast
tissue and is the most common site for breast tumors.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client
has a chest measurement of 42 inches, waist measurement of 45 inches, and hip
measurement of 50 inches. What important message should the nurse explain to the
client to promote health promotion?
A waist circumference greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease.
Rationale: Central (abdominal) obesity is associated with increased
cardiometabolic risk; waist >35 inches in women signals elevated risk independent
of BMI.
The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis?
Height reduction of 1.5 inches.
Rationale: Vertebral compression fractures and kyphosis from osteoporosis often
lead to measurable loss of height.
While conducting an interview to obtain a health history, the nurse notices that
the client pauses frequently and looks at the nurse expectantly. Which response is
best for the nurse to provide?
Sit quietly to allow the client to respond comfortably.
Rationale: Silence and presence give the client space to gather thoughts and
continue, which facilitates open communication.
A client is in the clinic for a yearly physical examination. Which action should
the nurse take when preparing to examine the client's abdomen?
Ask the client to urinate before beginning the examination.
Rationale: An empty bladder improves patient comfort and prevents bladder
distention from interfering with abdominal palpation.
Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute?
Bradypnea.
Rationale: Bradypnea is a respiratory rate below the normal adult range (typically
<12 breaths/min).
Which procedure should the nurse use to assess for a pulse deficit?
Measure the apical pulse and compare it to the peripheral pulse.
, Rationale: A pulse deficit is the difference between the apical (heart) rate and
peripheral (radial) pulse, indicating some contractions are not producing peripheral
pulses.
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the client's
lower lobes?
Dull, thud-like.
Rationale: Consolidation or collapse (atelectasis) produces a dull percussion note
compared with resonant lung tissue.
A client is being assessed upon admission to the medical-surgical unit. The nurse
is preparing to complete a head-to-toe assessment and will begin at the head of the
client. Which technique should the nurse use to begin the assessment?
Inspect the hair and skin.
Rationale: Inspection is the first step of physical exam (observe hair, scalp, and
skin for lesions, distribution, and hygiene).
The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta?
Deep palpation above and to the left of the umbilicus.
Rationale: The aorta lies in the midline slightly left of the umbilicus; deep
palpation in this area can detect pulsations or aneurysm.
The nurse is conducting a family history as part of the assessment interview.
Which action should the nurse take to ensure that sufficient information about the
client's blood relatives is obtained?
Document at least 3 generations of the client's family medical history.
Rationale: A three-generation pedigree captures hereditary patterns and risks for
common familial diseases.
The nurse is testing the client's shoulders for range of motion. What should the
nurse document to record normal internal rotation?
Range of 90 degrees when the hands are placed at the small of the back.
Rationale: Internal rotation to the small of the back (about 90°) represents normal
shoulder internal rotation ROM.
A client presents with a rash along the occipital area of the hairline and reports
intense itching. How should the nurse begin the objective part of the examination?
Actual Exam 2026/2027 Review
Nightingale College – Comprehensive
Preparation Guide with Detailed
Rationales & Key Nursing Concepts
The nurse is performing a thoracic assessment on a client with chronic asthma
and hyperinflation of the lungs. Which finding should be expected for this client?
Barrel chest.
Rationale: Chronic air trapping and hyperinflation (as in long-standing asthma or
COPD) cause increased anterior-posterior chest diameter, producing a barrel-
shaped chest.
The nurse is assessing bowel sounds for a hospitalized client. The nurse has
heard bowel sounds in the right upper quadrant. What action should the nurse take
next?
Note the character and frequency of bowel sounds.
Rationale: After detecting bowel sounds, you document their quality and
frequency (normal, hypoactive, hyperactive, borborygmi) rather than just location.
During inspection of a client's mouth and pharynx, the nurse places a tongue
blade on the back of the tongue which causes the client to gag. After removing the
tongue blade, what action should the nurse take?
Document an intact gag reflex.
Rationale: A gag response on stimulation of the posterior pharynx indicates the
glossopharyngeal and vagus reflexes are intact; this is appropriate to record.
When teaching a client how to perform a monthly breast self-assessment, the
nurse should tell the client that it is most important to assess which part of the
breast more closely for changes?
Upper outer quadrant.
,Rationale: The upper outer quadrant contains the greatest proportion of breast
tissue and is the most common site for breast tumors.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client
has a chest measurement of 42 inches, waist measurement of 45 inches, and hip
measurement of 50 inches. What important message should the nurse explain to the
client to promote health promotion?
A waist circumference greater than 35 inches in women puts you at higher
risk for type 2 diabetes and heart disease.
Rationale: Central (abdominal) obesity is associated with increased
cardiometabolic risk; waist >35 inches in women signals elevated risk independent
of BMI.
The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis?
Height reduction of 1.5 inches.
Rationale: Vertebral compression fractures and kyphosis from osteoporosis often
lead to measurable loss of height.
While conducting an interview to obtain a health history, the nurse notices that
the client pauses frequently and looks at the nurse expectantly. Which response is
best for the nurse to provide?
Sit quietly to allow the client to respond comfortably.
Rationale: Silence and presence give the client space to gather thoughts and
continue, which facilitates open communication.
A client is in the clinic for a yearly physical examination. Which action should
the nurse take when preparing to examine the client's abdomen?
Ask the client to urinate before beginning the examination.
Rationale: An empty bladder improves patient comfort and prevents bladder
distention from interfering with abdominal palpation.
Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute?
Bradypnea.
Rationale: Bradypnea is a respiratory rate below the normal adult range (typically
<12 breaths/min).
Which procedure should the nurse use to assess for a pulse deficit?
Measure the apical pulse and compare it to the peripheral pulse.
, Rationale: A pulse deficit is the difference between the apical (heart) rate and
peripheral (radial) pulse, indicating some contractions are not producing peripheral
pulses.
A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the client's
lower lobes?
Dull, thud-like.
Rationale: Consolidation or collapse (atelectasis) produces a dull percussion note
compared with resonant lung tissue.
A client is being assessed upon admission to the medical-surgical unit. The nurse
is preparing to complete a head-to-toe assessment and will begin at the head of the
client. Which technique should the nurse use to begin the assessment?
Inspect the hair and skin.
Rationale: Inspection is the first step of physical exam (observe hair, scalp, and
skin for lesions, distribution, and hygiene).
The nurse is assessing a healthy young adult during an annual physical
examination. Which assessment technique should the nurse implement when
palpating the abdominal aorta?
Deep palpation above and to the left of the umbilicus.
Rationale: The aorta lies in the midline slightly left of the umbilicus; deep
palpation in this area can detect pulsations or aneurysm.
The nurse is conducting a family history as part of the assessment interview.
Which action should the nurse take to ensure that sufficient information about the
client's blood relatives is obtained?
Document at least 3 generations of the client's family medical history.
Rationale: A three-generation pedigree captures hereditary patterns and risks for
common familial diseases.
The nurse is testing the client's shoulders for range of motion. What should the
nurse document to record normal internal rotation?
Range of 90 degrees when the hands are placed at the small of the back.
Rationale: Internal rotation to the small of the back (about 90°) represents normal
shoulder internal rotation ROM.
A client presents with a rash along the occipital area of the hairline and reports
intense itching. How should the nurse begin the objective part of the examination?
