BSN 246 HESI HEALTH ASSESSMENT V1 EXAM
2025/2026 (ACTUAL EXAM) QUESTIONS AND VERIFIED
ANSWERS (NIGHTINGALE COLLEGE)
The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be
expected for this client? - -------CORRECT ANSWER----Barrel chest
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? - -------CORRECT 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? - -
------CORRECT 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? - -------
CORRECT 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? - -------CORRECT 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? - -------CORRECT 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? - -------
CORRECT 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? - -------CORRECT 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? - -------CORRECT
ANSWER----Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - ----
---CORRECT 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? - -------CORRECT 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? - -------CORRECT 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? - -------CORRECT 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? - -------
CORRECT 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? - -------
CORRECT 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? - -------CORRECT ANSWER----Inspect the scalp
looking for nits.
The nurse is assessing a client's range of motion as the client bends the
right knee up to the chest while keeping the left leg straight, but is
unable to keep the left thigh on the table. The assessment is repeated
for the left knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - -------CORRECT
ANSWER----A flexion deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions
that are dark red in color and will not blanch. The lesions range from 1
to 3 mm in size. What is the first question the nurse should ask the
2025/2026 (ACTUAL EXAM) QUESTIONS AND VERIFIED
ANSWERS (NIGHTINGALE COLLEGE)
The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be
expected for this client? - -------CORRECT ANSWER----Barrel chest
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? - -------CORRECT 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? - -
------CORRECT 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? - -------
CORRECT 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? - -------CORRECT 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? - -------CORRECT 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? - -------
CORRECT 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? - -------CORRECT 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? - -------CORRECT
ANSWER----Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - ----
---CORRECT 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? - -------CORRECT 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? - -------CORRECT 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? - -------CORRECT 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? - -------
CORRECT 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? - -------
CORRECT 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? - -------CORRECT ANSWER----Inspect the scalp
looking for nits.
The nurse is assessing a client's range of motion as the client bends the
right knee up to the chest while keeping the left leg straight, but is
unable to keep the left thigh on the table. The assessment is repeated
for the left knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - -------CORRECT
ANSWER----A flexion deformity referred to as a positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions
that are dark red in color and will not blanch. The lesions range from 1
to 3 mm in size. What is the first question the nurse should ask the
