1
BSN 246
BSN 246 HESI HEALTH ASSESSMENT EXAM
(2025/ 2026 UPDATE) QUESTIONS &
ANSWERS| GRADE A| 100% CORRECT
(VERIFIED SOLUTIONS)
The registered nurse (RN) is caring for a client with aplastic
anemia who is hospitalized for weight loss and generalized
weakness. Laboratory values show a white blood count (WBC)
of 2,500/mm3 and a platelet countof 160,000/mm3. Which
intervention is the primary focus in the client's plan of care for
the RN to implement?
A. Assist with frequent ambulation.
B. Encourage visitors to visit.
C. Maintain strict protective precautions.
D. Avoid peripheral injections. - ANS ✓C. Maintain strict
protective precautions.
Rationale
The client should be under strict protective transmission
precautions because the WBC values are low and normal WBC
levels are 4,000-10,000/mm3, so the client is an increased high
risk for infection.
The registered nurse (RN) is teaching a client who is being
discharged after treatment of tuberculosis (TB). Which cultural
issues should the RN assess when preparing the client for
discharge? (Select all that apply.)
A. Native language.
B. Education level.
C. Type of lifestyle.
D. Financial resources.
BSN 246
, 2
BSN 246
E. Previous medical history. - ANS ✓A. Native language.
B. Education level.
C. Type of lifestyle.
D. Financial resources.
Rationale
To ensure compliance the client's native language, education
level, lifestyle, and financial resources should be considered
when preparing the client's discharge instructions about the
continuation of treatment for TB.
An older client is admitted to the hospital with severe diarrhea.
The registered nurse (RN) is completing an assessment and
notes the client has dry mucous membranes and poor skin
turgor. Which assessment data should the RN gather to
determine if the client has a fluid volume deficit?
A. Lower extremity edema.
B. Orthostatic hypotension.
C. Elevated blood pressure.
D. Cheyne-Stokes respirations. - ANS ✓B. Orthostatic
hypotension.
Rationale
Orthostatic hypotension can be a sign of fluid volume deficit in
an older client who has experienced severe diarrhea.
The registered nurse (RN) is caring for a client who has a
closed head injury from a motor vehicle collision. Which finding
should the RN assess the client for the risk of diabetes
insipidus (DI)?
A. High fever.
B. Low blood pressure.
C. Muscle rigidity.
D. Polydipsia. - ANS ✓D. Polydipsia.
BSN 246
, 3
BSN 246
Rationale
A characteristic finding of DI is excretion of large quantities of
urine (5 to 20L/day), and most clients compensate for fluid loss
by drinking large amounts of water (polydipsia). DI can occur
when there has been damage or injury to the pituitary gland or
hypothalamus as a result of head trauma, tumor or an illness
such as meningitis. This damage interrupts the ADH
production, storage and release causing the excessive
urination and thirst.
The registered nurse (RN) is teaching a client who is newly
diagnosed with emphysema how to perform pursed lip
breathing. What is the primary reason for teaching the client
this method of breathing?
A. Decreases respiratory rate.
B. Increases O2 saturation throughout the body.
C. Conserves energy while ambulating.
D. Promotes CO2 elimination. - ANS ✓D. Promotes CO2
elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive
pressure within the alveoli increasing the surface area of the
alveoli making it easier for the O2 and CO2 gas exchange to
occur .
The registered nurse (RN) is administering haloperidol 0.5 mg
IM PRN to a client for the first time. What side effects should
the RN assess the client for during the initial dose?
A. Bradykinesia.
B. Dystonia.
C. Somatization.
D. Akathisia. - ANS ✓B. Dystonia.
Rationale
BSN 246
, 4
BSN 246
Dystonia can be a sudden adverse reaction to this psychotropic
medication which should be discontinued to resolve dystonia,
and the healthcare provider notified immediately.
After a liver biopsy is performed at the bedside, the registered
nurse (RN) is assigned the care of the client. Which nursing
intervention is most important for the RN to implement?
A. Position client on left side with pillow placed under the costal
margin.
B. Assist the client with voiding immediately after the
procedure.
C. Evaluate vital signs q10 to 20 minutes for 2 hours after
procedure.
D. Ambulate client 3 times in first hour with pillow held at
abdomen. - ANS ✓C. Evaluate vital signs q10 to 20 minutes for
2 hours after procedure.
Rationale
Vital signs should be checked every 10 to 20 minutes to assess
for bleeding after biopsy of the liver, which is highly vascular.
The client should be positioned on the right sidewith a pillow or
sandbag under the costal margin and supporting the biopsy
site. The client should be maintained on bedrest for several
hours to decrease the risk of bleeding from the biopsy site.
A registered nurse (RN) is performing a mini-mental state
examination (MMSE) for a client who is being admitted to an
assisted living community. Which communication techniques
should the RN implement to decrease anxiety in the client?
(Select all that apply.)
A. Use simple sentences during the examination.
B. Move to another question if the client seems confused.
C. Reduce environmental detractors during the examination.
D. Allow family to answer for the client to decrease frustration.
BSN 246
BSN 246
BSN 246 HESI HEALTH ASSESSMENT EXAM
(2025/ 2026 UPDATE) QUESTIONS &
ANSWERS| GRADE A| 100% CORRECT
(VERIFIED SOLUTIONS)
The registered nurse (RN) is caring for a client with aplastic
anemia who is hospitalized for weight loss and generalized
weakness. Laboratory values show a white blood count (WBC)
of 2,500/mm3 and a platelet countof 160,000/mm3. Which
intervention is the primary focus in the client's plan of care for
the RN to implement?
A. Assist with frequent ambulation.
B. Encourage visitors to visit.
C. Maintain strict protective precautions.
D. Avoid peripheral injections. - ANS ✓C. Maintain strict
protective precautions.
Rationale
The client should be under strict protective transmission
precautions because the WBC values are low and normal WBC
levels are 4,000-10,000/mm3, so the client is an increased high
risk for infection.
The registered nurse (RN) is teaching a client who is being
discharged after treatment of tuberculosis (TB). Which cultural
issues should the RN assess when preparing the client for
discharge? (Select all that apply.)
A. Native language.
B. Education level.
C. Type of lifestyle.
D. Financial resources.
BSN 246
, 2
BSN 246
E. Previous medical history. - ANS ✓A. Native language.
B. Education level.
C. Type of lifestyle.
D. Financial resources.
Rationale
To ensure compliance the client's native language, education
level, lifestyle, and financial resources should be considered
when preparing the client's discharge instructions about the
continuation of treatment for TB.
An older client is admitted to the hospital with severe diarrhea.
The registered nurse (RN) is completing an assessment and
notes the client has dry mucous membranes and poor skin
turgor. Which assessment data should the RN gather to
determine if the client has a fluid volume deficit?
A. Lower extremity edema.
B. Orthostatic hypotension.
C. Elevated blood pressure.
D. Cheyne-Stokes respirations. - ANS ✓B. Orthostatic
hypotension.
Rationale
Orthostatic hypotension can be a sign of fluid volume deficit in
an older client who has experienced severe diarrhea.
The registered nurse (RN) is caring for a client who has a
closed head injury from a motor vehicle collision. Which finding
should the RN assess the client for the risk of diabetes
insipidus (DI)?
A. High fever.
B. Low blood pressure.
C. Muscle rigidity.
D. Polydipsia. - ANS ✓D. Polydipsia.
BSN 246
, 3
BSN 246
Rationale
A characteristic finding of DI is excretion of large quantities of
urine (5 to 20L/day), and most clients compensate for fluid loss
by drinking large amounts of water (polydipsia). DI can occur
when there has been damage or injury to the pituitary gland or
hypothalamus as a result of head trauma, tumor or an illness
such as meningitis. This damage interrupts the ADH
production, storage and release causing the excessive
urination and thirst.
The registered nurse (RN) is teaching a client who is newly
diagnosed with emphysema how to perform pursed lip
breathing. What is the primary reason for teaching the client
this method of breathing?
A. Decreases respiratory rate.
B. Increases O2 saturation throughout the body.
C. Conserves energy while ambulating.
D. Promotes CO2 elimination. - ANS ✓D. Promotes CO2
elimination.
Rationale
Pursed lip breathing helps eliminate CO2 by increasing positive
pressure within the alveoli increasing the surface area of the
alveoli making it easier for the O2 and CO2 gas exchange to
occur .
The registered nurse (RN) is administering haloperidol 0.5 mg
IM PRN to a client for the first time. What side effects should
the RN assess the client for during the initial dose?
A. Bradykinesia.
B. Dystonia.
C. Somatization.
D. Akathisia. - ANS ✓B. Dystonia.
Rationale
BSN 246
, 4
BSN 246
Dystonia can be a sudden adverse reaction to this psychotropic
medication which should be discontinued to resolve dystonia,
and the healthcare provider notified immediately.
After a liver biopsy is performed at the bedside, the registered
nurse (RN) is assigned the care of the client. Which nursing
intervention is most important for the RN to implement?
A. Position client on left side with pillow placed under the costal
margin.
B. Assist the client with voiding immediately after the
procedure.
C. Evaluate vital signs q10 to 20 minutes for 2 hours after
procedure.
D. Ambulate client 3 times in first hour with pillow held at
abdomen. - ANS ✓C. Evaluate vital signs q10 to 20 minutes for
2 hours after procedure.
Rationale
Vital signs should be checked every 10 to 20 minutes to assess
for bleeding after biopsy of the liver, which is highly vascular.
The client should be positioned on the right sidewith a pillow or
sandbag under the costal margin and supporting the biopsy
site. The client should be maintained on bedrest for several
hours to decrease the risk of bleeding from the biopsy site.
A registered nurse (RN) is performing a mini-mental state
examination (MMSE) for a client who is being admitted to an
assisted living community. Which communication techniques
should the RN implement to decrease anxiety in the client?
(Select all that apply.)
A. Use simple sentences during the examination.
B. Move to another question if the client seems confused.
C. Reduce environmental detractors during the examination.
D. Allow family to answer for the client to decrease frustration.
BSN 246
