BSN 246 HESI Health Assessment V1 Exam (2025/2026) – 3
Full Sets with Actual Questions and Verified Answers |
Complete Updated Version | Graded A+
The BSN 246 HESI Health Assessment V1 Exam (2025/2026 Edition) includes three
complete, verified sets of 50 questions each — exactly 150 questions total —
matching the official exam structure used at Nightingale College. Each set is NGN-style,
clinically accurate, and graded A+ with detailed rationales.
Introduction
This 2025/2026 edition provides realistic practice to master head-to-toe assessment, clinical
reasoning, and interpretation of findings. All questions are verified against current HESI
standards, NCLEX-RN competencies, and Nightingale College curriculum.
Answer Format
Correct answers are in bold and green with evidence-based rationales that reinforce
clinical judgment and assessment skills.
SET 1: 50 Questions (Actual Exam Version 1)
General Survey & Vital Signs (10 Questions)
1. A patient appears pale, diaphoretic, and clutching their chest. The nurse’s
priority action is to:
a) Complete the full assessment
b) Assess ABCs
c) Ask about pain
d) Take vital signs
Answer: b) Assess ABCs
Rationale: Acute distress with chest symptoms requires immediate airway, breathing,
circulation evaluation.
2. Blood pressure is 172/98 mmHg. Classification:
a) Normal
b) Elevated
c) Stage 1 HTN
d) Stage 2 HTN
Answer: d) Stage 2 HTN
Rationale: SBP ≥160 or DBP ≥100 = Stage 2.
,3. Radial pulse is 110 bpm and irregular. This is:
a) Normal sinus rhythm
b) Sinus tachycardia
c) Atrial fibrillation
d) Premature beats
Answer: c) Atrial fibrillation
Rationale: Irregularly irregular = AFib until proven otherwise.
4. Respiratory rate is 32/min with use of accessory muscles. This is:
a) Normal
b) Tachypnea
c) Dyspnea
d) Both b and c
Answer: d) Both b and c
Rationale: RR >20 + effort = tachypnea with dyspnea.
5. Capillary refill is 4 seconds in fingers and toes. This indicates:
a) Normal perfusion
b) Vasoconstriction
c) Shock
d) Hyperemia
Answer: c) Shock
Rationale: >3 seconds = poor perfusion.
6. BMI = 34 kg/m². Classification:
a) Overweight
b) Obesity Class I
c) Obesity Class II
d) Morbid obesity
Answer: b) Obesity Class I
Rationale: 30.0–34.9 = Class I.
7. Fingernails show clubbing with >180° angle. This suggests:
a) Acute infection
b) Chronic hypoxia
c) Trauma
d) Fungal infection
Answer: b) Chronic hypoxia
Rationale: Seen in COPD, lung CA, cyanotic heart disease.
8. Oral temperature is 39.4°C. This is:
a) Low-grade fever
b) Moderate fever
c) High fever
d) Hyperpyrexia
Answer: c) High fever
Rationale: 39.0–40.0°C = high fever.
, 9. The nurse uses OLDCARTS for symptom analysis. “S” stands for:
a) Site
b) Severity
c) Symptoms
d) Spread
Answer: b) Severity
Rationale: O-L-D-C-A-R-T-S: Severity (0–10 scale).
10. Pain is 8/10, sharp, radiates to back. The nurse documents:
a) Visceral pain
b) Somatic pain
c) Neuropathic pain
d) Psychogenic pain
Answer: a) Visceral pain
Rationale: Radiating, deep = visceral (e.g., pancreatitis).
HEENT (10 Questions)
11. Sclera is yellow. This indicates:
a) Anemia
b) Jaundice
c) Scleritis
d) Arcus senilis
Answer: b) Jaundice
Rationale: Bilirubin >2.5 mg/dL.
12. PERRLA is absent due to fixed pupils. This suggests:
a) Normal aging
b) CN III damage
c) Cataract
d) Glaucoma
Answer: b) CN III damage
Rationale: Fixed pupil = nerve compression or brain injury.
13. Visual acuity is 20/100 OU. This means:
a) Normal
b) Mild impairment
c) Moderate impairment
d) Legal blindness
Answer: c) Moderate impairment
Rationale: 20/70 to 20/160 = moderate.
14. Red reflex is absent in right eye. This suggests:
a) Normal
b) Cataract
c) Retinal detachment
Full Sets with Actual Questions and Verified Answers |
Complete Updated Version | Graded A+
The BSN 246 HESI Health Assessment V1 Exam (2025/2026 Edition) includes three
complete, verified sets of 50 questions each — exactly 150 questions total —
matching the official exam structure used at Nightingale College. Each set is NGN-style,
clinically accurate, and graded A+ with detailed rationales.
Introduction
This 2025/2026 edition provides realistic practice to master head-to-toe assessment, clinical
reasoning, and interpretation of findings. All questions are verified against current HESI
standards, NCLEX-RN competencies, and Nightingale College curriculum.
Answer Format
Correct answers are in bold and green with evidence-based rationales that reinforce
clinical judgment and assessment skills.
SET 1: 50 Questions (Actual Exam Version 1)
General Survey & Vital Signs (10 Questions)
1. A patient appears pale, diaphoretic, and clutching their chest. The nurse’s
priority action is to:
a) Complete the full assessment
b) Assess ABCs
c) Ask about pain
d) Take vital signs
Answer: b) Assess ABCs
Rationale: Acute distress with chest symptoms requires immediate airway, breathing,
circulation evaluation.
2. Blood pressure is 172/98 mmHg. Classification:
a) Normal
b) Elevated
c) Stage 1 HTN
d) Stage 2 HTN
Answer: d) Stage 2 HTN
Rationale: SBP ≥160 or DBP ≥100 = Stage 2.
,3. Radial pulse is 110 bpm and irregular. This is:
a) Normal sinus rhythm
b) Sinus tachycardia
c) Atrial fibrillation
d) Premature beats
Answer: c) Atrial fibrillation
Rationale: Irregularly irregular = AFib until proven otherwise.
4. Respiratory rate is 32/min with use of accessory muscles. This is:
a) Normal
b) Tachypnea
c) Dyspnea
d) Both b and c
Answer: d) Both b and c
Rationale: RR >20 + effort = tachypnea with dyspnea.
5. Capillary refill is 4 seconds in fingers and toes. This indicates:
a) Normal perfusion
b) Vasoconstriction
c) Shock
d) Hyperemia
Answer: c) Shock
Rationale: >3 seconds = poor perfusion.
6. BMI = 34 kg/m². Classification:
a) Overweight
b) Obesity Class I
c) Obesity Class II
d) Morbid obesity
Answer: b) Obesity Class I
Rationale: 30.0–34.9 = Class I.
7. Fingernails show clubbing with >180° angle. This suggests:
a) Acute infection
b) Chronic hypoxia
c) Trauma
d) Fungal infection
Answer: b) Chronic hypoxia
Rationale: Seen in COPD, lung CA, cyanotic heart disease.
8. Oral temperature is 39.4°C. This is:
a) Low-grade fever
b) Moderate fever
c) High fever
d) Hyperpyrexia
Answer: c) High fever
Rationale: 39.0–40.0°C = high fever.
, 9. The nurse uses OLDCARTS for symptom analysis. “S” stands for:
a) Site
b) Severity
c) Symptoms
d) Spread
Answer: b) Severity
Rationale: O-L-D-C-A-R-T-S: Severity (0–10 scale).
10. Pain is 8/10, sharp, radiates to back. The nurse documents:
a) Visceral pain
b) Somatic pain
c) Neuropathic pain
d) Psychogenic pain
Answer: a) Visceral pain
Rationale: Radiating, deep = visceral (e.g., pancreatitis).
HEENT (10 Questions)
11. Sclera is yellow. This indicates:
a) Anemia
b) Jaundice
c) Scleritis
d) Arcus senilis
Answer: b) Jaundice
Rationale: Bilirubin >2.5 mg/dL.
12. PERRLA is absent due to fixed pupils. This suggests:
a) Normal aging
b) CN III damage
c) Cataract
d) Glaucoma
Answer: b) CN III damage
Rationale: Fixed pupil = nerve compression or brain injury.
13. Visual acuity is 20/100 OU. This means:
a) Normal
b) Mild impairment
c) Moderate impairment
d) Legal blindness
Answer: c) Moderate impairment
Rationale: 20/70 to 20/160 = moderate.
14. Red reflex is absent in right eye. This suggests:
a) Normal
b) Cataract
c) Retinal detachment
