BSN 246 HESI HEALTH ASSESSMENT V1
EXAM 2025 to 2026 COMPREHENSIVE
STUDY GUIDE PRACTICE QUESTIONS
VERIFIED ANSWERS DETAILED
RATIONALES NIGHTINGALE COLLEGE
The nurse is assessing a client's middle lung lobe. What is the best location
for the nurse to place a stethoscope diaphragm to hear normal lung sounds
in this lobe? - CORRECT ANSWER-4th intercostal space, right
midclavicular line.
A Muslim male client refuses to let the female registered nurse (RN) listen
to his breath sounds during the examination. How should the RN respond?
- CORRECT ANSWER-Request a male nurse or healthcare provider
to perform the exam.
cultural issues to assess to prepare client for discharge - CORRECT
ANSWER-language, education level, lifestyle, financial resources,
Assessments to identify and document that are consistent with PUD (peptic
ulcer disease) - CORRECT ANSWER-hematemsis, gastric pain,
intolerance of spicy foods
steatorrhea - CORRECT ANSWER-fatty stool- not associated with
peptic ulcer disease (PUD)
,Common complications of systemic lupus erythematosus - CORRECT
ANSWER-weight loss, anorexia, depressed mood, break in tissue
integrity
Systemic lupus erythematosus (SLE)- complications that should be
reported immediately - CORRECT ANSWER-fever related to
infection- secondary infections are a major concern due to use of
corticosteroids and chemotherapeutic agents that suppress the immune
system
Common symptoms of viral gastroenteritis (stomach flu) - CORRECT
ANSWER-dehydration (from diarrhea and throwing up), dizziness when
ambulating due to fluid volume deficit, poor skin turgor, dry mucous
membranes and lips
Rebound abdominal tenderness over right lower quadrant - CORRECT
ANSWER-could be an indication of appendicitis- notify provider. It is
not common for those with gastroenteritis
weak pedal pulse and what else is consistent with diminished peripheral
circulation - CORRECT ANSWER-diminished hair on legs, skin cool
to touch (decreased arterial blood flow)
Common complications of immobility include - CORRECT
ANSWER-- stiff joints (early warning of contractures and atrophy)
- osteoporosis, decreased flexibility
- DVT, PE
,- orthostatic hypotension
- atelectasis and pneumonia
- retention, UTIs, kidney stones
- pressure ulcers
- depression, anxiety, cognitive decline
Early signs of hypovolemic shock - CORRECT ANSWER-- lethargy,
AMS
- tachycardia,
- cool, clammy, pale or mottled skin
tachypneic
decreased urine output (oliguria)
- delayed cap refill
Blood pressure doesn't decrease until later stages
asthma treated with Beta 2 receptor expected response - CORRECT
ANSWER-rapid resolution of wheezing
improved pulse ox
esophageal varices - CORRECT ANSWER-abnormally dilated veins
in lower esophagus. Caused by portal hypertension most common cause is
liver cirrhosis. high risk of rupturing.
- usually asymptotic until they rupture-
signs of bleeding
- hematemesis, melena (black tarry stools), anemia, hypovolemic shock
, nursing intervention most important for esophageal varices - CORRECT
ANSWER-monitoring infusing IV fluids and replacement blood
products- patient at risk of fluid volume deficit and hypovolemic shock if
varices rupture
important maintain hemodynamic stability
why do we combo drug therapies for TB? - CORRECT ANSWER-
development of resistant strains of TB is decreased with combo drugs and
ensure efficacy of treatment
What should the nurse prepare a patient for immediately after chest tube
removal? - CORRECT ANSWER-a chest xray- ensure that lung
expansion has been maintained after removal
diverticulosis - CORRECT ANSWER-small pouch like sacs form in
the colon- can be caused by chronic constipation (straining weakens colon
wall), low fiber diet, obesity, lack of exercise, smoking
how does liver cirrhosis lead to varicose veins in the esophagus? -
CORRECT ANSWER-increased portal pressure- shunts blood glow to
esophageal vessels
paroxysmal nocturnal dyspnea (PND) - CORRECT ANSWER-sudden
and severe SOB that occurs at night most common cause is left-sided heart
failure
EXAM 2025 to 2026 COMPREHENSIVE
STUDY GUIDE PRACTICE QUESTIONS
VERIFIED ANSWERS DETAILED
RATIONALES NIGHTINGALE COLLEGE
The nurse is assessing a client's middle lung lobe. What is the best location
for the nurse to place a stethoscope diaphragm to hear normal lung sounds
in this lobe? - CORRECT ANSWER-4th intercostal space, right
midclavicular line.
A Muslim male client refuses to let the female registered nurse (RN) listen
to his breath sounds during the examination. How should the RN respond?
- CORRECT ANSWER-Request a male nurse or healthcare provider
to perform the exam.
cultural issues to assess to prepare client for discharge - CORRECT
ANSWER-language, education level, lifestyle, financial resources,
Assessments to identify and document that are consistent with PUD (peptic
ulcer disease) - CORRECT ANSWER-hematemsis, gastric pain,
intolerance of spicy foods
steatorrhea - CORRECT ANSWER-fatty stool- not associated with
peptic ulcer disease (PUD)
,Common complications of systemic lupus erythematosus - CORRECT
ANSWER-weight loss, anorexia, depressed mood, break in tissue
integrity
Systemic lupus erythematosus (SLE)- complications that should be
reported immediately - CORRECT ANSWER-fever related to
infection- secondary infections are a major concern due to use of
corticosteroids and chemotherapeutic agents that suppress the immune
system
Common symptoms of viral gastroenteritis (stomach flu) - CORRECT
ANSWER-dehydration (from diarrhea and throwing up), dizziness when
ambulating due to fluid volume deficit, poor skin turgor, dry mucous
membranes and lips
Rebound abdominal tenderness over right lower quadrant - CORRECT
ANSWER-could be an indication of appendicitis- notify provider. It is
not common for those with gastroenteritis
weak pedal pulse and what else is consistent with diminished peripheral
circulation - CORRECT ANSWER-diminished hair on legs, skin cool
to touch (decreased arterial blood flow)
Common complications of immobility include - CORRECT
ANSWER-- stiff joints (early warning of contractures and atrophy)
- osteoporosis, decreased flexibility
- DVT, PE
,- orthostatic hypotension
- atelectasis and pneumonia
- retention, UTIs, kidney stones
- pressure ulcers
- depression, anxiety, cognitive decline
Early signs of hypovolemic shock - CORRECT ANSWER-- lethargy,
AMS
- tachycardia,
- cool, clammy, pale or mottled skin
tachypneic
decreased urine output (oliguria)
- delayed cap refill
Blood pressure doesn't decrease until later stages
asthma treated with Beta 2 receptor expected response - CORRECT
ANSWER-rapid resolution of wheezing
improved pulse ox
esophageal varices - CORRECT ANSWER-abnormally dilated veins
in lower esophagus. Caused by portal hypertension most common cause is
liver cirrhosis. high risk of rupturing.
- usually asymptotic until they rupture-
signs of bleeding
- hematemesis, melena (black tarry stools), anemia, hypovolemic shock
, nursing intervention most important for esophageal varices - CORRECT
ANSWER-monitoring infusing IV fluids and replacement blood
products- patient at risk of fluid volume deficit and hypovolemic shock if
varices rupture
important maintain hemodynamic stability
why do we combo drug therapies for TB? - CORRECT ANSWER-
development of resistant strains of TB is decreased with combo drugs and
ensure efficacy of treatment
What should the nurse prepare a patient for immediately after chest tube
removal? - CORRECT ANSWER-a chest xray- ensure that lung
expansion has been maintained after removal
diverticulosis - CORRECT ANSWER-small pouch like sacs form in
the colon- can be caused by chronic constipation (straining weakens colon
wall), low fiber diet, obesity, lack of exercise, smoking
how does liver cirrhosis lead to varicose veins in the esophagus? -
CORRECT ANSWER-increased portal pressure- shunts blood glow to
esophageal vessels
paroxysmal nocturnal dyspnea (PND) - CORRECT ANSWER-sudden
and severe SOB that occurs at night most common cause is left-sided heart
failure
