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BSN 246 HESI Health Assessment
Remediation (Latest 2025/2026 Update)
Questions and Verified Answers | 100%
Correct | Grade A – Nightingale
Question 1: During a physical assessment of a 45-year-old patient, the nurse
notes jugular venous distention (JVD). Which action should the nurse take next?
A. Elevate the head of the bed to 45 degrees and measure the height of the pulsation above the
sternal angle.
B. Palpate the carotid artery simultaneously to assess for thrills.
C. Auscultate the lungs for adventitious sounds.
D. Document the finding as normal for age.
Correct Answer: A
Rationale: JVD is assessed by elevating the head of the bed to 45 degrees and measuring the
height of the jugular vein pulsation above the sternal angle; normal is less than 3-4 cm. This
confirms the presence and degree of elevation. Option B is incorrect as simultaneous palpation
can artifactually increase JVD readings. Option C, while important for fluid overload, is not the
immediate next step for JVD assessment. Option D is wrong because JVD is not a normal
finding and may indicate right-sided heart failure or increased central venous pressure.
Question 2: The nurse is performing a respiratory assessment on an elderly
patient with COPD. Which technique is most appropriate for assessing lung
expansion?
A. Ask the patient to take a deep breath and observe for symmetrical chest rise.
B. Percuss the posterior thorax while the patient exhales fully.
C. Auscultate breath sounds in a supine position.
D. Measure the anteroposterior diameter with a tape measure.
Correct Answer: A
Rationale: Observing symmetrical chest rise during deep inspiration evaluates diaphragmatic
excursion and lung expansion, crucial in COPD for detecting barrel chest or asymmetry. Option
B assesses density, not expansion. Option C is for breath sound quality, not expansion. Option D
measures chest shape but not dynamic expansion.
Question 3: When assessing a patient's peripheral pulses, the nurse rates the
radial pulse as +1. What does this indicate?
A. Bounding and forceful pulse.
B. Easily palpable but diminished.
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C. Absent pulse.
D. Normal, easily felt pulse.
Correct Answer: B
Rationale: A +1 pulse is diminished, easily palpable but weaker than normal, often seen in
hypovolemia or peripheral artery disease. Option A is +4 (bounding). Option C is 0 (absent).
Option D is +2 or +3 (normal).
Question 4: A patient reports sharp, stabbing chest pain on inspiration. During
assessment, the nurse should prioritize which technique?
A. Deep palpation of the chest wall.
B. Percussion of the affected area.
C. Auscultation during full inspiration and expiration.
D. Inspection for paradoxical chest movement.
Correct Answer: D
Rationale: Pleuritic pain suggests possible pneumothorax or rib fracture; inspecting for
paradoxical movement (flail chest) is priority to assess respiratory stability. Option A risks
worsening pain or injury. Option B is for dullness/fluid. Option C evaluates sounds but not
mechanics first.
Question 5: In assessing a newborn's fontanelles, the nurse notes the anterior
fontanelle is bulging. This finding is most indicative of:
A. Dehydration.
B. Increased intracranial pressure.
C. Normal variation in crying.
D. Prematurity.
Correct Answer: B
Rationale: Bulging anterior fontanelle in a calm infant signals increased ICP, requiring urgent
evaluation. Option A causes sunken fontanelles. Option C is transient during crying but resolves
quickly. Option D may have larger fontanelles, but bulging is abnormal.
Question 6: The nurse is assessing a patient's skin turgor on the forearm. Which
finding is consistent with moderate dehydration?
A. Skin snaps back immediately.
B. Skin tents for 2-3 seconds before returning.
C. Skin feels cool and clammy.
D. Skin has poor elasticity but returns slowly.
Correct Answer: B
BSN 246 HESI Health Assessment
Remediation (Latest 2025/2026 Update)
Questions and Verified Answers | 100%
Correct | Grade A – Nightingale
Question 1: During a physical assessment of a 45-year-old patient, the nurse
notes jugular venous distention (JVD). Which action should the nurse take next?
A. Elevate the head of the bed to 45 degrees and measure the height of the pulsation above the
sternal angle.
B. Palpate the carotid artery simultaneously to assess for thrills.
C. Auscultate the lungs for adventitious sounds.
D. Document the finding as normal for age.
Correct Answer: A
Rationale: JVD is assessed by elevating the head of the bed to 45 degrees and measuring the
height of the jugular vein pulsation above the sternal angle; normal is less than 3-4 cm. This
confirms the presence and degree of elevation. Option B is incorrect as simultaneous palpation
can artifactually increase JVD readings. Option C, while important for fluid overload, is not the
immediate next step for JVD assessment. Option D is wrong because JVD is not a normal
finding and may indicate right-sided heart failure or increased central venous pressure.
Question 2: The nurse is performing a respiratory assessment on an elderly
patient with COPD. Which technique is most appropriate for assessing lung
expansion?
A. Ask the patient to take a deep breath and observe for symmetrical chest rise.
B. Percuss the posterior thorax while the patient exhales fully.
C. Auscultate breath sounds in a supine position.
D. Measure the anteroposterior diameter with a tape measure.
Correct Answer: A
Rationale: Observing symmetrical chest rise during deep inspiration evaluates diaphragmatic
excursion and lung expansion, crucial in COPD for detecting barrel chest or asymmetry. Option
B assesses density, not expansion. Option C is for breath sound quality, not expansion. Option D
measures chest shape but not dynamic expansion.
Question 3: When assessing a patient's peripheral pulses, the nurse rates the
radial pulse as +1. What does this indicate?
A. Bounding and forceful pulse.
B. Easily palpable but diminished.
, 2
C. Absent pulse.
D. Normal, easily felt pulse.
Correct Answer: B
Rationale: A +1 pulse is diminished, easily palpable but weaker than normal, often seen in
hypovolemia or peripheral artery disease. Option A is +4 (bounding). Option C is 0 (absent).
Option D is +2 or +3 (normal).
Question 4: A patient reports sharp, stabbing chest pain on inspiration. During
assessment, the nurse should prioritize which technique?
A. Deep palpation of the chest wall.
B. Percussion of the affected area.
C. Auscultation during full inspiration and expiration.
D. Inspection for paradoxical chest movement.
Correct Answer: D
Rationale: Pleuritic pain suggests possible pneumothorax or rib fracture; inspecting for
paradoxical movement (flail chest) is priority to assess respiratory stability. Option A risks
worsening pain or injury. Option B is for dullness/fluid. Option C evaluates sounds but not
mechanics first.
Question 5: In assessing a newborn's fontanelles, the nurse notes the anterior
fontanelle is bulging. This finding is most indicative of:
A. Dehydration.
B. Increased intracranial pressure.
C. Normal variation in crying.
D. Prematurity.
Correct Answer: B
Rationale: Bulging anterior fontanelle in a calm infant signals increased ICP, requiring urgent
evaluation. Option A causes sunken fontanelles. Option C is transient during crying but resolves
quickly. Option D may have larger fontanelles, but bulging is abnormal.
Question 6: The nurse is assessing a patient's skin turgor on the forearm. Which
finding is consistent with moderate dehydration?
A. Skin snaps back immediately.
B. Skin tents for 2-3 seconds before returning.
C. Skin feels cool and clammy.
D. Skin has poor elasticity but returns slowly.
Correct Answer: B
