BSN 246 HESI HEALTH ASSESSMENT
AND FUNDAMENTALS V1 PRACTICE
EXAM
1. A client with a history of heart failure is admitted with dependent edema and dyspnea.
Which assessment finding should the nurse report to the healthcare provider immediately?
A. Pitting edema +2 in the lower extremities
B. Heart rate of 92 beats per minute
C. Weight gain of 3 lbs in the last 24 hours
D. Coarse crackles heard at the lung bases
Answer: D
Conceptual Explanation: While weight gain and edema are expected in heart failure,
crackles indicate pulmonary edema, which is a life-threatening complication requiring
immediate intervention.
2. The nurse is caring for a client with a potassium level of 6.2 mEq/L. Which EKG change
should the nurse expect to see?
A. Prominent U waves
,B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Conceptual Explanation: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests as
tall, peaked T waves and widened QRS complexes on an EKG.
3. A client is prescribed Lithium for bipolar disorder. Which instruction is most important for
the nurse to include in the discharge teaching?
A. Maintain a consistent intake of dietary sodium
B. Avoid sun exposure and use high-SPF sunscreen
C. Take the medication only when feeling manic
D. Limit fluid intake to 1 liter per day
Answer: A
Conceptual Explanation: Lithium is a salt; low sodium levels can cause the kidneys to
retain lithium, leading to toxicity. Consistent sodium intake is vital.
4. A nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding
requires immediate notification of the Rapid Response Team?
A. Calf pain on dorsiflexion of the foot
B. Swelling and redness of the affected leg
, C. Sudden onset of shortness of breath and chest pain
D. A localized area of warmth over the calf
Answer: C
Conceptual Explanation: Sudden dyspnea and chest pain are classic signs of a pulmonary
embolism, which is a frequent and fatal complication of DVT.
5. Which assessment finding in a post-operative client should the nurse prioritize?
A. Pain level of 7 out of 10
B. Urine output of 20 mL/hr for the last two hours
C. Absent bowel sounds 4 hours post-surgery
D. Sanguineous drainage on the surgical dressing
Answer: B
Conceptual Explanation: Urine output less than 30 mL/hr indicates poor renal perfusion
and potential hypovolemic shock or renal failure.
6. A client with Type 1 Diabetes is found unconscious and diaphoretic. What is the nurse’s
first action?
A. Administer 10 units of regular insulin subcutaneous
B. Check the client’s blood glucose level
C. Call the family to determine the last meal time
AND FUNDAMENTALS V1 PRACTICE
EXAM
1. A client with a history of heart failure is admitted with dependent edema and dyspnea.
Which assessment finding should the nurse report to the healthcare provider immediately?
A. Pitting edema +2 in the lower extremities
B. Heart rate of 92 beats per minute
C. Weight gain of 3 lbs in the last 24 hours
D. Coarse crackles heard at the lung bases
Answer: D
Conceptual Explanation: While weight gain and edema are expected in heart failure,
crackles indicate pulmonary edema, which is a life-threatening complication requiring
immediate intervention.
2. The nurse is caring for a client with a potassium level of 6.2 mEq/L. Which EKG change
should the nurse expect to see?
A. Prominent U waves
,B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Conceptual Explanation: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests as
tall, peaked T waves and widened QRS complexes on an EKG.
3. A client is prescribed Lithium for bipolar disorder. Which instruction is most important for
the nurse to include in the discharge teaching?
A. Maintain a consistent intake of dietary sodium
B. Avoid sun exposure and use high-SPF sunscreen
C. Take the medication only when feeling manic
D. Limit fluid intake to 1 liter per day
Answer: A
Conceptual Explanation: Lithium is a salt; low sodium levels can cause the kidneys to
retain lithium, leading to toxicity. Consistent sodium intake is vital.
4. A nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding
requires immediate notification of the Rapid Response Team?
A. Calf pain on dorsiflexion of the foot
B. Swelling and redness of the affected leg
, C. Sudden onset of shortness of breath and chest pain
D. A localized area of warmth over the calf
Answer: C
Conceptual Explanation: Sudden dyspnea and chest pain are classic signs of a pulmonary
embolism, which is a frequent and fatal complication of DVT.
5. Which assessment finding in a post-operative client should the nurse prioritize?
A. Pain level of 7 out of 10
B. Urine output of 20 mL/hr for the last two hours
C. Absent bowel sounds 4 hours post-surgery
D. Sanguineous drainage on the surgical dressing
Answer: B
Conceptual Explanation: Urine output less than 30 mL/hr indicates poor renal perfusion
and potential hypovolemic shock or renal failure.
6. A client with Type 1 Diabetes is found unconscious and diaphoretic. What is the nurse’s
first action?
A. Administer 10 units of regular insulin subcutaneous
B. Check the client’s blood glucose level
C. Call the family to determine the last meal time
