BSN 246 HESI Health Assessment Exam V2 Latest Update
1. A nurse performs a general survey on an older adult. Which finding
requires immediate follow-up?
A) Blood pressure 138/88 mm Hg
B) Asymmetrical facial drooping
C) Trace edema in both feet
D) Hearing loss with cupping of ear
Rationale: Asymmetrical facial drooping suggests a possible stroke,
requiring urgent neurologic assessment.
2. During palpation of a client’s abdomen, the nurse notes a firm, non-
tender mass in the right lower quadrant. The client reports no pain.
What is the best action?
A) Notify the provider immediately
B) Document finding and reassess in 4 hours
C) Prepare for a CT scan
D) Palpate more deeply to confirm
Rationale: A non-tender mass may be a normal structure (e.g.,
cecum); immediate intervention is not needed without other
symptoms.
3. A client reports crushing chest pain radiating to the left arm with
nausea and diaphoresis. What is the priority action?
A) Give sublingual nitroglycerin
,B) Check blood pressure
C) Obtain a 12-lead ECG
D) Administer morphine for pain
Rationale: These symptoms are classic for acute myocardial
infarction; ECG is priority to identify ischemic changes.
4. Which technique should the nurse use to assess deep tendon
reflexes?
A) Tap the tendon gently with fingertips
B) Strike the tendon briskly with a reflex hammer
C) Ask the client to contract the muscle voluntarily
D) Palpate the tendon during passive stretch
Rationale: A quick, direct strike elicits the stretch reflex; tapping too
slowly or softly will not produce a response.
5. A client’s oxygen saturation is 88% on room air. What is the
nurse’s priority?
A) Apply oxygen at 2 L/min via nasal cannula
B) Reposition the client to supine
C) Draw arterial blood gases
D) Auscultate lung sounds first
Rationale: SpO2 < 90% indicates hypoxemia; oxygen therapy is the
initial intervention.
6. When auscultating heart sounds, the nurse hears a “lub-dub”
rhythm with an extra sound after “dub.” This extra sound is most
,likely:
A) S4 gallop
B) S3 gallop
C) Systolic click
D) Pericardial friction rub
Rationale: S3 occurs in early diastole after S2, often indicating
volume overload or heart failure.
7. A client with dark skin has a newly inflamed wound. How should
the nurse assess for erythema?
A) Inspect for bright red discoloration
B) Ask the client if the area feels red
C) Palpate for warmth and assess for purple-red discoloration
D) Elevate the area and wait 10 minutes
Rationale: In dark skin, erythema appears as dark purple or deep
red; warmth and induration are reliable signs.
8. The nurse is assessing cranial nerve III (oculomotor). Which action
should the client perform?
A) Stick out the tongue
B) Smile and show teeth
C) Shrug shoulders against resistance
D) Follow the nurse’s finger with eyes only
Rationale: CN III controls extraocular movements (except lateral
rectus and superior oblique), pupil constriction, and lid elevation.
, 9. Which finding indicates a positive Homan’s sign?
A) Calf pain on dorsiflexion of the foot
B) Foot numbness with plantar flexion
C) Toes turning blue with elevation
D) Thigh swelling with knee extension
Rationale: Homan’s sign is calf pain upon dorsiflexion, historically
used for DVT suspicion.
10. A client has jaundice, scleral icterus, and dark urine. These
findings are most consistent with:
A) Pancreatitis
B) Liver dysfunction
C) Kidney stones
D) Severe anemia
Rationale: Jaundice and scleral icterus indicate elevated bilirubin
from hepatic or post-hepatic causes.
11. During a respiratory assessment, the nurse notes decreased breath
sounds at the left lung base. What is the next best action?
A) Refer for chest X-ray
B) Percuss the left base for dullness
C) Ask the client to take deeper breaths
D) Palpate for tactile fremitus
Rationale: Shallow breathing can cause false decreased sounds;
deeper breaths help differentiate true from artifactual findings.
1. A nurse performs a general survey on an older adult. Which finding
requires immediate follow-up?
A) Blood pressure 138/88 mm Hg
B) Asymmetrical facial drooping
C) Trace edema in both feet
D) Hearing loss with cupping of ear
Rationale: Asymmetrical facial drooping suggests a possible stroke,
requiring urgent neurologic assessment.
2. During palpation of a client’s abdomen, the nurse notes a firm, non-
tender mass in the right lower quadrant. The client reports no pain.
What is the best action?
A) Notify the provider immediately
B) Document finding and reassess in 4 hours
C) Prepare for a CT scan
D) Palpate more deeply to confirm
Rationale: A non-tender mass may be a normal structure (e.g.,
cecum); immediate intervention is not needed without other
symptoms.
3. A client reports crushing chest pain radiating to the left arm with
nausea and diaphoresis. What is the priority action?
A) Give sublingual nitroglycerin
,B) Check blood pressure
C) Obtain a 12-lead ECG
D) Administer morphine for pain
Rationale: These symptoms are classic for acute myocardial
infarction; ECG is priority to identify ischemic changes.
4. Which technique should the nurse use to assess deep tendon
reflexes?
A) Tap the tendon gently with fingertips
B) Strike the tendon briskly with a reflex hammer
C) Ask the client to contract the muscle voluntarily
D) Palpate the tendon during passive stretch
Rationale: A quick, direct strike elicits the stretch reflex; tapping too
slowly or softly will not produce a response.
5. A client’s oxygen saturation is 88% on room air. What is the
nurse’s priority?
A) Apply oxygen at 2 L/min via nasal cannula
B) Reposition the client to supine
C) Draw arterial blood gases
D) Auscultate lung sounds first
Rationale: SpO2 < 90% indicates hypoxemia; oxygen therapy is the
initial intervention.
6. When auscultating heart sounds, the nurse hears a “lub-dub”
rhythm with an extra sound after “dub.” This extra sound is most
,likely:
A) S4 gallop
B) S3 gallop
C) Systolic click
D) Pericardial friction rub
Rationale: S3 occurs in early diastole after S2, often indicating
volume overload or heart failure.
7. A client with dark skin has a newly inflamed wound. How should
the nurse assess for erythema?
A) Inspect for bright red discoloration
B) Ask the client if the area feels red
C) Palpate for warmth and assess for purple-red discoloration
D) Elevate the area and wait 10 minutes
Rationale: In dark skin, erythema appears as dark purple or deep
red; warmth and induration are reliable signs.
8. The nurse is assessing cranial nerve III (oculomotor). Which action
should the client perform?
A) Stick out the tongue
B) Smile and show teeth
C) Shrug shoulders against resistance
D) Follow the nurse’s finger with eyes only
Rationale: CN III controls extraocular movements (except lateral
rectus and superior oblique), pupil constriction, and lid elevation.
, 9. Which finding indicates a positive Homan’s sign?
A) Calf pain on dorsiflexion of the foot
B) Foot numbness with plantar flexion
C) Toes turning blue with elevation
D) Thigh swelling with knee extension
Rationale: Homan’s sign is calf pain upon dorsiflexion, historically
used for DVT suspicion.
10. A client has jaundice, scleral icterus, and dark urine. These
findings are most consistent with:
A) Pancreatitis
B) Liver dysfunction
C) Kidney stones
D) Severe anemia
Rationale: Jaundice and scleral icterus indicate elevated bilirubin
from hepatic or post-hepatic causes.
11. During a respiratory assessment, the nurse notes decreased breath
sounds at the left lung base. What is the next best action?
A) Refer for chest X-ray
B) Percuss the left base for dullness
C) Ask the client to take deeper breaths
D) Palpate for tactile fremitus
Rationale: Shallow breathing can cause false decreased sounds;
deeper breaths help differentiate true from artifactual findings.
