Nightingale College
ISEH · 642 NSB
NIGHTINGALE
BSN Program — HESI Health Assessment
EST. 2005
N U R T U R I N G T H E N E X T G E N E R AT I O N O F N U R S E S
BSN 246 HESI Health Assessment — Comprehensive
Review
N I G H T I N GA L E CO L L E G E — B AC H E LO R O F S C I E N C E I N N U RS I N G
INSTITUTION Nightingale College PROGRAM Bachelor of Science in Nursing
(BSN)
COURSE CODE BSN 246 COURSE TITLE HESI Health Assessment —
Comprehensive Review
ACADEMIC YEAR EXAM TITLE BSN 246 HESI Health Assessment
— Comprehensive Review
TOTAL QUESTIONS 112 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions require choosing all correct options.
▸ Health assessment techniques, normal vs. abnormal findings, and clinical reasoning are all testable
content.
▸ Priority-setting and patient safety considerations are emphasized.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All clinical data reflects current evidence-based practice and HESI/Nursing program standards.
, SECTION I — COMPREHENSIVE HEALTH ASSESSMENT &
Questions 1 – 112
CLINICAL FINDINGS
1. While assessing a client, the nurse notices that the client's legs are asymmetrical. Which
additional physical data should the nurse collect?
A. Perform passive range of motion and compare the findings
B. Compare measured circumferences of each extremity joint
C. Instruct client to walk across room and observe the gait
D. Measure the length of each leg and document the findings
CORRECT ANSWER D — Measure the length of each leg and document the findings
RATIONALE When assessing asymmetrical legs, the nurse should measure the length of each
leg to determine if there is a true discrepancy. Leg length discrepancy can affect
gait and posture. The measurement is taken from the anterior superior iliac spine
to the medial malleolus. If a discrepancy is found, further evaluation is needed.
2. While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases
of both lungs posteriorly. Which action should the nurse take in response to this finding?
A. Report the client's abnormal lung sounds to the healthcare provider
B. Continue with the remainder of the client's physical assessment
C. Ask the client to cough and then auscultate at the site again
D. Measure the client's oxygen saturation with a pulse oximeter
CORRECT ANSWER B — Continue with the remainder of the client's physical assessment
RATIONALE Vesicular breath sounds are normal lung sounds heard over peripheral lung fields,
including the bases posteriorly. They are soft, low-pitched sounds heard during
inspiration. Since this is a normal finding, the nurse should continue with the
remainder of the physical assessment without concern.
,3. The nurse observes the presence of brittle, concave curves to the nails of a client on
assessment. Which information should the nurse obtain from the client that may explain
the appearance of the nails?
A. Coronary heart disease
B. Iron deficiency anemia
C. Diabetes mellitus
D. Recent candida infection
CORRECT ANSWER B — Iron deficiency anemia
RATIONALE Brittle, concave nails (koilonychia or spoon nails) are associated with iron
deficiency anemia. This condition causes the nails to become thin, brittle, and
concave with raised edges. The nurse should assess for other signs of anemia
such as pallor, fatigue, and low hemoglobin levels.
4. Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute
old client has a gestational age of 42 weeks. Based on this finding, which intervention is
most important for the nurse to implement?
A. Apply a pulse oximeter to the foot
B. Draw arterial blood gases
C. Obtain a capillary blood glucose
D. Provide blow by oxygen
CORRECT ANSWER C — Obtain a capillary blood glucose
RATIONALE Post-term infants (gestational age >42 weeks) are at increased risk for
hypoglycemia due to depletion of glycogen stores. The most important
intervention is to obtain a capillary blood glucose to assess for hypoglycemia.
These infants may also have meconium aspiration and other complications
requiring monitoring.
, 5. The nurse is performing an admission assessment for a client with pyelonephritis who has
urgency and burning while urinating. Which finding indicates an expected response when
the nurse percusses the costovertebral angle?
A. Audible thud without pain
B. Rigidity and firmness
C. Rebound tenderness
D. Sharp, severe pain
CORRECT ANSWER D — Sharp, severe pain
RATIONALE In pyelonephritis, percussion of the costovertebral angle (CVA) typically elicits
sharp, severe pain (positive CVA tenderness). This indicates inflammation of the
kidney. The absence of pain with an audible thud would be a normal finding.
Rebound tenderness is associated with peritoneal inflammation.
6. In assessing a client's nailbeds, the nurse notes that the angle between the nail and the
nailbed is 200 degrees. Which action should the nurse take?
A. Determine the client's most recent hemoglobin level
B. Document the presence of nailbed clubbing
C. Administer a PRN prescription for oxygen
D. Consult with a podiatrist to trim the client's toenails
CORRECT ANSWER B — Document the presence of nailbed clubbing
RATIONALE A normal nail angle is approximately 160 degrees. An angle greater than 180
degrees (200 degrees) indicates nailbed clubbing, which is associated with
chronic hypoxia, lung disease, or cardiovascular conditions. The nurse should
document the finding and assess for underlying causes.
ISEH · 642 NSB
NIGHTINGALE
BSN Program — HESI Health Assessment
EST. 2005
N U R T U R I N G T H E N E X T G E N E R AT I O N O F N U R S E S
BSN 246 HESI Health Assessment — Comprehensive
Review
N I G H T I N GA L E CO L L E G E — B AC H E LO R O F S C I E N C E I N N U RS I N G
INSTITUTION Nightingale College PROGRAM Bachelor of Science in Nursing
(BSN)
COURSE CODE BSN 246 COURSE TITLE HESI Health Assessment —
Comprehensive Review
ACADEMIC YEAR EXAM TITLE BSN 246 HESI Health Assessment
— Comprehensive Review
TOTAL QUESTIONS 112 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions require choosing all correct options.
▸ Health assessment techniques, normal vs. abnormal findings, and clinical reasoning are all testable
content.
▸ Priority-setting and patient safety considerations are emphasized.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All clinical data reflects current evidence-based practice and HESI/Nursing program standards.
, SECTION I — COMPREHENSIVE HEALTH ASSESSMENT &
Questions 1 – 112
CLINICAL FINDINGS
1. While assessing a client, the nurse notices that the client's legs are asymmetrical. Which
additional physical data should the nurse collect?
A. Perform passive range of motion and compare the findings
B. Compare measured circumferences of each extremity joint
C. Instruct client to walk across room and observe the gait
D. Measure the length of each leg and document the findings
CORRECT ANSWER D — Measure the length of each leg and document the findings
RATIONALE When assessing asymmetrical legs, the nurse should measure the length of each
leg to determine if there is a true discrepancy. Leg length discrepancy can affect
gait and posture. The measurement is taken from the anterior superior iliac spine
to the medial malleolus. If a discrepancy is found, further evaluation is needed.
2. While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases
of both lungs posteriorly. Which action should the nurse take in response to this finding?
A. Report the client's abnormal lung sounds to the healthcare provider
B. Continue with the remainder of the client's physical assessment
C. Ask the client to cough and then auscultate at the site again
D. Measure the client's oxygen saturation with a pulse oximeter
CORRECT ANSWER B — Continue with the remainder of the client's physical assessment
RATIONALE Vesicular breath sounds are normal lung sounds heard over peripheral lung fields,
including the bases posteriorly. They are soft, low-pitched sounds heard during
inspiration. Since this is a normal finding, the nurse should continue with the
remainder of the physical assessment without concern.
,3. The nurse observes the presence of brittle, concave curves to the nails of a client on
assessment. Which information should the nurse obtain from the client that may explain
the appearance of the nails?
A. Coronary heart disease
B. Iron deficiency anemia
C. Diabetes mellitus
D. Recent candida infection
CORRECT ANSWER B — Iron deficiency anemia
RATIONALE Brittle, concave nails (koilonychia or spoon nails) are associated with iron
deficiency anemia. This condition causes the nails to become thin, brittle, and
concave with raised edges. The nurse should assess for other signs of anemia
such as pallor, fatigue, and low hemoglobin levels.
4. Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute
old client has a gestational age of 42 weeks. Based on this finding, which intervention is
most important for the nurse to implement?
A. Apply a pulse oximeter to the foot
B. Draw arterial blood gases
C. Obtain a capillary blood glucose
D. Provide blow by oxygen
CORRECT ANSWER C — Obtain a capillary blood glucose
RATIONALE Post-term infants (gestational age >42 weeks) are at increased risk for
hypoglycemia due to depletion of glycogen stores. The most important
intervention is to obtain a capillary blood glucose to assess for hypoglycemia.
These infants may also have meconium aspiration and other complications
requiring monitoring.
, 5. The nurse is performing an admission assessment for a client with pyelonephritis who has
urgency and burning while urinating. Which finding indicates an expected response when
the nurse percusses the costovertebral angle?
A. Audible thud without pain
B. Rigidity and firmness
C. Rebound tenderness
D. Sharp, severe pain
CORRECT ANSWER D — Sharp, severe pain
RATIONALE In pyelonephritis, percussion of the costovertebral angle (CVA) typically elicits
sharp, severe pain (positive CVA tenderness). This indicates inflammation of the
kidney. The absence of pain with an audible thud would be a normal finding.
Rebound tenderness is associated with peritoneal inflammation.
6. In assessing a client's nailbeds, the nurse notes that the angle between the nail and the
nailbed is 200 degrees. Which action should the nurse take?
A. Determine the client's most recent hemoglobin level
B. Document the presence of nailbed clubbing
C. Administer a PRN prescription for oxygen
D. Consult with a podiatrist to trim the client's toenails
CORRECT ANSWER B — Document the presence of nailbed clubbing
RATIONALE A normal nail angle is approximately 160 degrees. An angle greater than 180
degrees (200 degrees) indicates nailbed clubbing, which is associated with
chronic hypoxia, lung disease, or cardiovascular conditions. The nurse should
document the finding and assess for underlying causes.
