Nightingale College
ISEH · 642 NSB
NIGHTINGALE
BSN Program — HESI Health Assessment Part II
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
HESI BSN 246 Part II
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 Part II
ACADEMIC YEAR EXAM TITLE HESI BSN 246 Part II
TOTAL QUESTIONS 102 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.
▸ Medical-surgical nursing, pathophysiology, pharmacology, and health assessment are all testable
content.
▸ Priority-setting, patient safety, and clinical reasoning 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 MEDICAL-SURGICAL
Questions 1 – 102
NURSING & HEALTH ASSESSMENT
1. An adult client trapped in a burning house has suffered burns to the back of the head,
upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what
does the nurse determine the extent of the burn injury to be? (Enter the answer in the
space provided.)
A. 18%
B. 22.5%
C. 27%
D. 31.5%
CORRECT ANSWER B — 22.5%
RATIONALE Using the rule of nines: back of the head = 4.5% (9% × 0.5), upper half of posterior
trunk = 9% (18% × 0.5), back of both arms = 9% (4.5% each arm × 2). Total = 4.5 + 9
+ 9 = 22.5%. The rule of nines is used to estimate total body surface area (TBSA)
burned in adults.
2. The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor.
Which of the following is the most characteristic manifestation of cancer at this site?
A. Bright red blood in the stool
B. Dull abdominal pain exacerbated by walking
C. Change in bowel habits
D. Narrowing of stool caliber
CORRECT ANSWER B — Dull abdominal pain exacerbated by walking
RATIONALE Right colon tumors commonly present with dull abdominal pain that may be
exacerbated by walking, as well as anemia, weight loss, and a palpable mass. Left
colon tumors are more likely to cause changes in bowel habits, narrowing of stool
caliber, and bright red blood in the stool. The presentation varies by location.
,3. The nurse is reading the operative record of a client who had cardiac surgery and notes
that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the
cardiac output results leads the nurse to make which of the following conclusions?
A. The cardiac output is within normal range
B. The cardiac output is below the normal range
C. The cardiac output is above the normal range
D. The cardiac output indicates hyperdynamic circulation
CORRECT ANSWER B — The cardiac output is below the normal range
RATIONALE Normal cardiac output is 4-8 L/min. A cardiac output of 3.2 L/min is below the
normal range. This indicates decreased cardiac function and may lead to
insufficient tissue perfusion. The nurse should monitor for signs of decreased
cardiac output including hypotension, tachycardia, and altered mental status.
4. The nurse is assessing the client's muscle strength and notes that when asked, the client
cannot maintain his or her hands in a supinated position with the arms extended and eyes
closed. How would the nurse correctly document this finding on the medical record?
A. Client is exhibiting pronator drift
B. Client has positive Romberg test
C. Client has decreased muscle tone
D. Client is experiencing muscle weakness
CORRECT ANSWER A — Client is exhibiting pronator drift
RATIONALE Pronator drift is an abnormal neurological finding where the client cannot
maintain hands in a supinated position with arms extended and eyes closed. This
indicates upper motor neuron weakness. The pronator drift test is a sensitive
indicator of subtle motor weakness, often associated with cerebrovascular
accidents or other neurological conditions.
, 5. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash
noted across the nose. The nurse interprets that this finding is consistent with early
manifestations of which of the following disorders?
A. Rosacea
B. Systemic lupus erythematosus (SLE)
C. Contact dermatitis
D. Psoriasis
CORRECT ANSWER B — Systemic lupus erythematosus (SLE)
RATIONALE A butterfly (malar) rash across the nose and cheeks is a classic early manifestation
of systemic lupus erythematosus (SLE). This rash is erythematous, may be raised
or flat, and spares the nasolabial folds. It is triggered by sun exposure in many
clients and is one of the diagnostic criteria for SLE.
6. The client is diagnosed with a full-thickness burn. The nurse understands that which of
the following structural areas of the skin is involved?
A. Epidermis only
B. Epidermis and upper dermis
C. Epidermis, entire dermis, and epithelial portion of subcutaneous fat
D. Epidermis, dermis, and all subcutaneous tissue
CORRECT ANSWER C — Epidermis, entire dermis, and epithelial portion of subcutaneous fat
RATIONALE A full-thickness burn (third-degree burn) involves the epidermis, entire dermis,
and the epithelial portion of the subcutaneous fat. These burns appear white,
charred, or leathery and are painless because nerve endings have been
destroyed. Full-thickness burns require skin grafting for healing.
ISEH · 642 NSB
NIGHTINGALE
BSN Program — HESI Health Assessment Part II
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
HESI BSN 246 Part II
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 Part II
ACADEMIC YEAR EXAM TITLE HESI BSN 246 Part II
TOTAL QUESTIONS 102 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.
▸ Medical-surgical nursing, pathophysiology, pharmacology, and health assessment are all testable
content.
▸ Priority-setting, patient safety, and clinical reasoning 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 MEDICAL-SURGICAL
Questions 1 – 102
NURSING & HEALTH ASSESSMENT
1. An adult client trapped in a burning house has suffered burns to the back of the head,
upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what
does the nurse determine the extent of the burn injury to be? (Enter the answer in the
space provided.)
A. 18%
B. 22.5%
C. 27%
D. 31.5%
CORRECT ANSWER B — 22.5%
RATIONALE Using the rule of nines: back of the head = 4.5% (9% × 0.5), upper half of posterior
trunk = 9% (18% × 0.5), back of both arms = 9% (4.5% each arm × 2). Total = 4.5 + 9
+ 9 = 22.5%. The rule of nines is used to estimate total body surface area (TBSA)
burned in adults.
2. The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor.
Which of the following is the most characteristic manifestation of cancer at this site?
A. Bright red blood in the stool
B. Dull abdominal pain exacerbated by walking
C. Change in bowel habits
D. Narrowing of stool caliber
CORRECT ANSWER B — Dull abdominal pain exacerbated by walking
RATIONALE Right colon tumors commonly present with dull abdominal pain that may be
exacerbated by walking, as well as anemia, weight loss, and a palpable mass. Left
colon tumors are more likely to cause changes in bowel habits, narrowing of stool
caliber, and bright red blood in the stool. The presentation varies by location.
,3. The nurse is reading the operative record of a client who had cardiac surgery and notes
that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the
cardiac output results leads the nurse to make which of the following conclusions?
A. The cardiac output is within normal range
B. The cardiac output is below the normal range
C. The cardiac output is above the normal range
D. The cardiac output indicates hyperdynamic circulation
CORRECT ANSWER B — The cardiac output is below the normal range
RATIONALE Normal cardiac output is 4-8 L/min. A cardiac output of 3.2 L/min is below the
normal range. This indicates decreased cardiac function and may lead to
insufficient tissue perfusion. The nurse should monitor for signs of decreased
cardiac output including hypotension, tachycardia, and altered mental status.
4. The nurse is assessing the client's muscle strength and notes that when asked, the client
cannot maintain his or her hands in a supinated position with the arms extended and eyes
closed. How would the nurse correctly document this finding on the medical record?
A. Client is exhibiting pronator drift
B. Client has positive Romberg test
C. Client has decreased muscle tone
D. Client is experiencing muscle weakness
CORRECT ANSWER A — Client is exhibiting pronator drift
RATIONALE Pronator drift is an abnormal neurological finding where the client cannot
maintain hands in a supinated position with arms extended and eyes closed. This
indicates upper motor neuron weakness. The pronator drift test is a sensitive
indicator of subtle motor weakness, often associated with cerebrovascular
accidents or other neurological conditions.
, 5. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash
noted across the nose. The nurse interprets that this finding is consistent with early
manifestations of which of the following disorders?
A. Rosacea
B. Systemic lupus erythematosus (SLE)
C. Contact dermatitis
D. Psoriasis
CORRECT ANSWER B — Systemic lupus erythematosus (SLE)
RATIONALE A butterfly (malar) rash across the nose and cheeks is a classic early manifestation
of systemic lupus erythematosus (SLE). This rash is erythematous, may be raised
or flat, and spares the nasolabial folds. It is triggered by sun exposure in many
clients and is one of the diagnostic criteria for SLE.
6. The client is diagnosed with a full-thickness burn. The nurse understands that which of
the following structural areas of the skin is involved?
A. Epidermis only
B. Epidermis and upper dermis
C. Epidermis, entire dermis, and epithelial portion of subcutaneous fat
D. Epidermis, dermis, and all subcutaneous tissue
CORRECT ANSWER C — Epidermis, entire dermis, and epithelial portion of subcutaneous fat
RATIONALE A full-thickness burn (third-degree burn) involves the epidermis, entire dermis,
and the epithelial portion of the subcutaneous fat. These burns appear white,
charred, or leathery and are painless because nerve endings have been
destroyed. Full-thickness burns require skin grafting for healing.
