BSN 246 HESI HEALTH ASSESSMENT PRACTICE
EXAM V1 AND V2 2026 QUESTIONS AND
VERIFIED ANSWERS COMPLETE SET
◉ What is the best initial response by the nurse? Answer: Describe
the location and type of pain you are having
◉ Based on the nurse's assessment, which assessment data supports
the decision to administer pain medication as the first intervention?
(Select all that apply. One, some, or all options may be correct.)
Answer: Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood
pressure of 132/76 mmHg
◉ Which action should the nurse implement first? Answer:
Administer an analgesic.
◉ Which interventions are important to include in the client's plan
of care while receiving multiple immunosuppressants? (Select all
that apply. One, some, or all options may be correct.) Answer:
Instruct client to wear a mask when walking in the halls. - Instruct
visitors that fresh flowers should not be taken into the room. -
Monitor immunosuppression drug levels regularly.
,◉ Which intervention should the nurse ensure is included in the
plan of care during the immediate postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. Answer: a
◉ Which is the priority nursing assessment during the first 24-hour
postoperative period? Answer: Vital signs
◉ The nurse is teaching the patient about fluid management
between dialysis treatments. Which instruction by the nurse is the
most accurate? Answer: Limit fluids in between treatments to
minimize the amount of fluid that needs to be removed during
dialysis.
◉ Which expected outcome should be included in the nurse's
teaching plan? Answer: Client will avoid canned and processed
foods.
◉ The nurse assesses the dialysis graft. Which assessment should be
reported to the healthcare provider (HCP) immediately? (Select all
that apply. One, some, or all options may be correct.) Answer: Yellow,
purulent drainage from graft incision site. - Absence of a thrill over
,the graft site. - Capillary refill >10 seconds in the hand where the
graft is placed.
◉ Which intervention should the nurse ensure has been include in
the client's plan of care? (Select all that apply. One, some, or all
options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-
lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E. Assess Judy's distal pulses and circulation in the arm with the
access Answer: B. Perform sterile dressing changes at the dual
lumen catheter site - E. Assess the client's distal pulses and
circulation in the arm with the access.
◉ The nurse documents the assessment of the arteriovenous (AV)
graft. Which documentation best describes a properly functioning
AV graft? Answer: Thrill present and palpated
◉ The client asks the nurse to clarify what palliative care involves.
Which explanation provides the client the best education regarding
palliative care? (Select all that apply. One, some, or all options may
be correct.) Answer: Palliative care provides relief from symptoms
, including pain. - Palliative care supports holistic care and improves
quality of life. -
◉ What complication would the client be most concerned about if
choosing peritoneal dialysis? Answer: Abdominal
infection/Peritonitis
◉ The nurse prepares and instructs the client for hemodialysis.
Which statements by the client indicate the need for further
education? (Select all that apply. One, some, or all options may be
correct.) Answer: Hemodialysis will help restore kidney function
back to a normal level. - Bowel or bladder perforation may occur
with hemodialysis catheter placement.
◉ What action should the nurse take based on the response from the
healthcare provider (HCP) phone call? (Select all that apply. One,
some, or all options may be correct.) Answer: Document both phone
calls and the HCP's prescriptions. - Notify the charge nurse and
activate the chain of command - Hold the potassium chloride
◉ Which intervention should the nurse implement? Answer: Call
and speak directly with the healthcare provider (HCP).
◉ Which intervention is most important for the nurse to implement?
Answer: Hold the dose of potassium chloride and contact the HCP to
report the serum potassium level.
EXAM V1 AND V2 2026 QUESTIONS AND
VERIFIED ANSWERS COMPLETE SET
◉ What is the best initial response by the nurse? Answer: Describe
the location and type of pain you are having
◉ Based on the nurse's assessment, which assessment data supports
the decision to administer pain medication as the first intervention?
(Select all that apply. One, some, or all options may be correct.)
Answer: Pain rating of 6/10 - Heart rate of 102 beats/minute - Blood
pressure of 132/76 mmHg
◉ Which action should the nurse implement first? Answer:
Administer an analgesic.
◉ Which interventions are important to include in the client's plan
of care while receiving multiple immunosuppressants? (Select all
that apply. One, some, or all options may be correct.) Answer:
Instruct client to wear a mask when walking in the halls. - Instruct
visitors that fresh flowers should not be taken into the room. -
Monitor immunosuppression drug levels regularly.
,◉ Which intervention should the nurse ensure is included in the
plan of care during the immediate postoperative period?
a. Monitor Judy's urinary output hourly using an urimeter.
b. Assess Judy's surgical incision every shift.
c. Monitor Judy's nasogastric tube every 4 hours.
d. Encourage Judy to use the incentive spirometer daily. Answer: a
◉ Which is the priority nursing assessment during the first 24-hour
postoperative period? Answer: Vital signs
◉ The nurse is teaching the patient about fluid management
between dialysis treatments. Which instruction by the nurse is the
most accurate? Answer: Limit fluids in between treatments to
minimize the amount of fluid that needs to be removed during
dialysis.
◉ Which expected outcome should be included in the nurse's
teaching plan? Answer: Client will avoid canned and processed
foods.
◉ The nurse assesses the dialysis graft. Which assessment should be
reported to the healthcare provider (HCP) immediately? (Select all
that apply. One, some, or all options may be correct.) Answer: Yellow,
purulent drainage from graft incision site. - Absence of a thrill over
,the graft site. - Capillary refill >10 seconds in the hand where the
graft is placed.
◉ Which intervention should the nurse ensure has been include in
the client's plan of care? (Select all that apply. One, some, or all
options may be correct.)
A. Instruct lab personnel to obtain blood specimens from the dual-
lumen catheter.
B. Perform sterile dressing changes at the dual-lumen catheter site.
C. Empty and record the drainage from the graft tubing regularly.
D. Regularly rotate IV insertion sites above and below the graft site.
E. Assess Judy's distal pulses and circulation in the arm with the
access Answer: B. Perform sterile dressing changes at the dual
lumen catheter site - E. Assess the client's distal pulses and
circulation in the arm with the access.
◉ The nurse documents the assessment of the arteriovenous (AV)
graft. Which documentation best describes a properly functioning
AV graft? Answer: Thrill present and palpated
◉ The client asks the nurse to clarify what palliative care involves.
Which explanation provides the client the best education regarding
palliative care? (Select all that apply. One, some, or all options may
be correct.) Answer: Palliative care provides relief from symptoms
, including pain. - Palliative care supports holistic care and improves
quality of life. -
◉ What complication would the client be most concerned about if
choosing peritoneal dialysis? Answer: Abdominal
infection/Peritonitis
◉ The nurse prepares and instructs the client for hemodialysis.
Which statements by the client indicate the need for further
education? (Select all that apply. One, some, or all options may be
correct.) Answer: Hemodialysis will help restore kidney function
back to a normal level. - Bowel or bladder perforation may occur
with hemodialysis catheter placement.
◉ What action should the nurse take based on the response from the
healthcare provider (HCP) phone call? (Select all that apply. One,
some, or all options may be correct.) Answer: Document both phone
calls and the HCP's prescriptions. - Notify the charge nurse and
activate the chain of command - Hold the potassium chloride
◉ Which intervention should the nurse implement? Answer: Call
and speak directly with the healthcare provider (HCP).
◉ Which intervention is most important for the nurse to implement?
Answer: Hold the dose of potassium chloride and contact the HCP to
report the serum potassium level.
