BSN 246 HESI Health Assessment Exam V3 (2025/2026 Update)
– 100% Correct Questions and Verified Answers | Grade A –
Nightingale
Practice Questions
Question 1. What is the initial step when performing a physical assessment of the ab-
domen?
A. Auscultation
B. Palpation
C. Inspection
D. Percussion
Answer: C. Inspection
Explanation: Nightingale’s HESI framework emphasizes inspection as the
first step in abdominal assessment to observe for distension, scars, or asym-
metry. Auscultation follows to avoid altering bowel sounds, while palpation
and percussion are performed last.
Question 2. During a cardiovascular assessment, a patient reports chest pain. What is
the nurse’s priority action?
A. Auscultate heart sounds
B. Assess pain characteristics
C. Administer nitroglycerin
D. Obtain a 12-lead ECG
Answer: B. Assess pain characteristics
Explanation: Per Nightingale’s HESI standards, assessing pain characteris-
tics (e.g., onset, location, duration) is the priority to determine the cause of
chest pain. Administering medication or obtaining an ECG requires further
data, and auscultation is secondary.
Question 3. Which cranial nerve is tested by having the patient follow a penlight with
their eyes?
A. Optic (II)
B. Oculomotor (III)
C. Trigeminal (V)
D. Facial (VII)
Answer: B. Oculomotor (III)
Explanation: Nightingale’s HESI neurological assessment guidelines specify
that the oculomotor nerve (III) is tested by assessing extraocular movements,
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, as it controls most eye muscles. Optic tests vision, trigeminal tests sensation,
and facial tests expression.
Question 4. Which respiratory finding indicates a potential abnormality?
A. Respiratory rate of 16 breaths per minute
B. Symmetrical chest expansion
C. Wheezing on expiration
D. Clear lung sounds bilaterally
Answer: C. Wheezing on expiration
Explanation: Nightingale’s HESI curriculum identifies wheezing as an abnor-
mal finding, suggesting airway narrowing (e.g., asthma). Normal respiratory
rate (12–20), symmetrical expansion, and clear lung sounds are expected
findings.
Question 5. What is the correct sequence for assessing vital signs?
A. Pulse, respirations, blood pressure, temperature
B. Temperature, pulse, respirations, blood pressure
C. Blood pressure, temperature, pulse, respirations
D. Respirations, pulse, temperature, blood pressure
Answer: B. Temperature, pulse, respirations, blood pressure
Explanation: Nightingale’s HESI framework recommends this sequence to
minimize patient activity, which could affect respirations or blood pressure,
ensuring accurate measurements.
Question 6. A Glasgow Coma Scale score of 12 indicates what level of impairment?
A. None
B. Mild
C. Moderate
D. Severe
Answer: C. Moderate
Explanation: Nightingale’s HESI standards classify a Glasgow Coma Scale
score of 9–12 as moderate impairment, indicating neurological compromise
that requires close monitoring.
Question 7. Where should the nurse place the stethoscope to auscultate the aortic valve?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, midclavicular line
C. Second intercostal space, left sternal border
D. Fourth intercostal space, left sternal border
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– 100% Correct Questions and Verified Answers | Grade A –
Nightingale
Practice Questions
Question 1. What is the initial step when performing a physical assessment of the ab-
domen?
A. Auscultation
B. Palpation
C. Inspection
D. Percussion
Answer: C. Inspection
Explanation: Nightingale’s HESI framework emphasizes inspection as the
first step in abdominal assessment to observe for distension, scars, or asym-
metry. Auscultation follows to avoid altering bowel sounds, while palpation
and percussion are performed last.
Question 2. During a cardiovascular assessment, a patient reports chest pain. What is
the nurse’s priority action?
A. Auscultate heart sounds
B. Assess pain characteristics
C. Administer nitroglycerin
D. Obtain a 12-lead ECG
Answer: B. Assess pain characteristics
Explanation: Per Nightingale’s HESI standards, assessing pain characteris-
tics (e.g., onset, location, duration) is the priority to determine the cause of
chest pain. Administering medication or obtaining an ECG requires further
data, and auscultation is secondary.
Question 3. Which cranial nerve is tested by having the patient follow a penlight with
their eyes?
A. Optic (II)
B. Oculomotor (III)
C. Trigeminal (V)
D. Facial (VII)
Answer: B. Oculomotor (III)
Explanation: Nightingale’s HESI neurological assessment guidelines specify
that the oculomotor nerve (III) is tested by assessing extraocular movements,
1
, as it controls most eye muscles. Optic tests vision, trigeminal tests sensation,
and facial tests expression.
Question 4. Which respiratory finding indicates a potential abnormality?
A. Respiratory rate of 16 breaths per minute
B. Symmetrical chest expansion
C. Wheezing on expiration
D. Clear lung sounds bilaterally
Answer: C. Wheezing on expiration
Explanation: Nightingale’s HESI curriculum identifies wheezing as an abnor-
mal finding, suggesting airway narrowing (e.g., asthma). Normal respiratory
rate (12–20), symmetrical expansion, and clear lung sounds are expected
findings.
Question 5. What is the correct sequence for assessing vital signs?
A. Pulse, respirations, blood pressure, temperature
B. Temperature, pulse, respirations, blood pressure
C. Blood pressure, temperature, pulse, respirations
D. Respirations, pulse, temperature, blood pressure
Answer: B. Temperature, pulse, respirations, blood pressure
Explanation: Nightingale’s HESI framework recommends this sequence to
minimize patient activity, which could affect respirations or blood pressure,
ensuring accurate measurements.
Question 6. A Glasgow Coma Scale score of 12 indicates what level of impairment?
A. None
B. Mild
C. Moderate
D. Severe
Answer: C. Moderate
Explanation: Nightingale’s HESI standards classify a Glasgow Coma Scale
score of 9–12 as moderate impairment, indicating neurological compromise
that requires close monitoring.
Question 7. Where should the nurse place the stethoscope to auscultate the aortic valve?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, midclavicular line
C. Second intercostal space, left sternal border
D. Fourth intercostal space, left sternal border
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