BSN 246 HESI HEALTH EXAM REVIEW
UPDATED COMPLETE QUESTIONS AND
ANSWERS GRADED A+
◉ 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? Answer: Note the character and frequency
of bowel sounds
◉ 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? Answer: Document an intact gag reflex.
◉ 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? Answer:
Upper outer quadrant.
◉ 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? Answer: A waist circumference is greater than 35
inches in women puts you at higher risk for type 2 diabetes and heart
disease."
,◉ The nurse performs a physical assessment on an older female
client. Which change from the prior exam may be an indication of
osteoporosis? Answer: Height reduction of 1.5 inches.
◉ 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? Answer:
Sit quietly to allow the client to respond comfortably.
◉ A client is in the clinical for a yearly physical examination. Which
action should the nurse take when preparing to examine the client's
abdomen? Answer: Ask the client to urinate before beginning the
examination.
◉ Which respiratory condition should the nurse document after
measuring a respiratory rate of 8 breaths/minute? Answer: Bradypnea.
◉ Which procedure should the nurse use to assessfor a pulse deficit?
Answer: Measure the apical pulse and compare it to the peripheral
pulse.
*A pulse deficit is a palpable difference between the apical pulse at
the point of maximal impulse and the radial pulse palpated at the
wrist.
, ◉ 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? Answer: Dull, thud-like.
◉ 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? Answer: Inspect the hair and skin.
◉ 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? Answer: Deep
palpation above and to the left of the umbilicus.
◉ 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? Answer:
Document at least 3 generations of the client's family medical history.
◉ The nurse is testing the client's shoulders for range of motion. What
should the nurse document to record normal internal rotation?
Answer: Range of 90 degrees when the hands are placed at the small
of the back.
◉ 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? Answer: Inspect the scalp looking for nits.
UPDATED COMPLETE QUESTIONS AND
ANSWERS GRADED A+
◉ 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? Answer: Note the character and frequency
of bowel sounds
◉ 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? Answer: Document an intact gag reflex.
◉ 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? Answer:
Upper outer quadrant.
◉ 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? Answer: A waist circumference is greater than 35
inches in women puts you at higher risk for type 2 diabetes and heart
disease."
,◉ The nurse performs a physical assessment on an older female
client. Which change from the prior exam may be an indication of
osteoporosis? Answer: Height reduction of 1.5 inches.
◉ 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? Answer:
Sit quietly to allow the client to respond comfortably.
◉ A client is in the clinical for a yearly physical examination. Which
action should the nurse take when preparing to examine the client's
abdomen? Answer: Ask the client to urinate before beginning the
examination.
◉ Which respiratory condition should the nurse document after
measuring a respiratory rate of 8 breaths/minute? Answer: Bradypnea.
◉ Which procedure should the nurse use to assessfor a pulse deficit?
Answer: Measure the apical pulse and compare it to the peripheral
pulse.
*A pulse deficit is a palpable difference between the apical pulse at
the point of maximal impulse and the radial pulse palpated at the
wrist.
, ◉ 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? Answer: Dull, thud-like.
◉ 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? Answer: Inspect the hair and skin.
◉ 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? Answer: Deep
palpation above and to the left of the umbilicus.
◉ 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? Answer:
Document at least 3 generations of the client's family medical history.
◉ The nurse is testing the client's shoulders for range of motion. What
should the nurse document to record normal internal rotation?
Answer: Range of 90 degrees when the hands are placed at the small
of the back.
◉ 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? Answer: Inspect the scalp looking for nits.
