Exam – Nightingale College Practice
Questions with Verified Answers &
Rationales
Exam Overview
The BSN 246 HESI Health Assessment V2 exam evaluates nursing
students' competency in performing comprehensive health
assessments, including physical examination techniques, health
history collection, and clinical evaluation of findings across all body
systems -
2
-
3
.
SECTION 1: FUNDAMENTALS OF ASSESSMENT
1. Which assessment technique is always performed first when
examining any body system?
,A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D. Inspection
Rationale: Inspection precedes all other assessment techniques
because it allows observation of general appearance, symmetry, and
surface characteristics before altering tissue or sound. Palpation and
percussion can alter findings, making inspection the priority first step -
2
.
2. During an abdominal assessment, the nurse auscultates before
palpating. What is the primary rationale for this sequence?
A. To warm up the stethoscope diaphragm
B. To prevent altering the frequency of bowel sounds
C. To allow the patient to relax before palpation
D. To identify areas of tenderness before palpation
Answer: B. To prevent altering the frequency of bowel sounds
Rationale: Palpation can increase peristalsis or alter bowel sounds;
auscultation must occur first to get an accurate baseline -
6
.
3. Which of the following represents subjective data?
A. Blood pressure 120/80 mmHg
B. Liver palpable 2 cm below costal margin
, C. Patient states, "I feel like my heart is skipping beats."
D. Pupils equal, round, and reactive to light
Answer: C. Patient states, "I feel like my heart is skipping beats."
Rationale: Subjective data are symptoms reported by the patient that
cannot be verified by the examiner. Objective data are measurable and
observable (A, B, D) -
6
.
4. The nurse is preparing to assess a patient who just had a left total
hip arthroplasty. What is the priority action regarding patient
positioning?
A. Place the patient in a supine position with legs crossed
B. Position the patient in high Fowler's to assess the lungs
C. Maintain abduction of the left hip and avoid adduction
D. Place the patient in Sims' position for comfort
Answer: C. Maintain abduction of the left hip and avoid adduction
Rationale: Post-hip arthroplasty, the hip must be maintained in
abduction using a pillow to prevent dislocation; adduction is
contraindicated -
6
.
5. A patient with a history of heart failure presents with shortness of
breath. The nurse places the patient in a sitting position leaning
forward. This position is known as: