BSN 246 HESI 1 UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
Question:
1. An older client pushes the nurse's hand away when palpation is initiated during physical assessment.
Which additional objective sign aids the nurse in assessing for abdominal tenderness?
Answer:
Rebound tenderness.
Rationale An objective sign that can aid in determining abdominal tenderness is the assessment of rebound
tenderness when the person reports abdominal pain or when you elicit tenderness during palpation.
Question:
2. The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the
nurse document that are consistent with diminished peripheral circulation? (Select all that apply.)
Answer:
Diminished hair on leg and .Skin cool to touch. Rationale Diminished hair on the legs and skin that is cool
to touch are expectant signs of decreased arterial blood flow.
Question:
3. An older client has just returned to the room following a surgical procedure. Which pain scale should the
nurse use when assessing the client's pain level?
Answer:
Verbal descriptor scale.
Rationale The descriptor scale uses words rather than numbers or pictures to describe pain. This method of
reporting pain is less confusing and less abstract for older adults. The choices provided for rating the
intensity of pain include the following: no pain, mild pain, moderate pain, and severe pain.
Question:
4. How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart
failure?
Answer:
Measure bilateral ankle circumference with a non-stretchable tape measure. Rationale An accurate
assessment of lower extremity edema is required when a client is treated for heart failure. Measuring ankle
circumference is more accurate than other objective measures that can rely on individual interpretation,
such as measuring pitting edema.
Question:
5. The nurse is testing the client's shoulders for range of motion. What should the nurse document to record
normal internal rotation?
Answer:
Range of 90 degrees when the hands are placed at the small of the back.
Rationale To document normal internal rotation of the shoulders, the client should be able to demonstrate a
range of 90 degrees when the hands are placed at the small of the back.
, Question:
6. The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which further
assessment of the area should the nurse perform?
Answer:
Observe the direction of movement.
Rationale Increased peristaltic movements are occasionally seen in very thin clients and may indicate the
presence of intestinal obstruction. In addition to noting the quadrant of origin, the nurse should also note
the direction of the peristaltic flow and report these findings to the healthcare provider.
Question:
7. The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the
right upper quadrant. Which action should the nurse take next?
Answer:
Note the character and frequency of bowel sounds.
Rationale Bowel sounds originate from the air and fluid movement through the stomach and intestines. A
wide range of normal sounds can occur depending on when the last meal was ingested. The nurse should
assess for hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency.
It is not necessary to count the number of bowel sounds per minute and to listen to all four quadrants. It is
necessary to listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
Question:
8. Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which
additional assessment should the nurse use to verify splenomegaly?
Answer:
Percussion
Rationale When splenomegaly is suspected, percussion of the spleen produces a dull sound and is a safe
method of verifying enlargement.
Question:
9. The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to
visualize?
Answer:
Pharynx
Rationale Depressing the tongue when examining the mouth allows the nurse to visualize the pharynx,
tonsils, and adenoids.
Question:
10. When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound. Which
lung sound should the nurse document?
Answer:
Stridor
Rationale Stridor is an audible monophonic inspiratory crowing sound. Stridor in a client with dyspnea
indicates airway obstruction.
CORRECT ANSWERS
Question:
1. An older client pushes the nurse's hand away when palpation is initiated during physical assessment.
Which additional objective sign aids the nurse in assessing for abdominal tenderness?
Answer:
Rebound tenderness.
Rationale An objective sign that can aid in determining abdominal tenderness is the assessment of rebound
tenderness when the person reports abdominal pain or when you elicit tenderness during palpation.
Question:
2. The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the
nurse document that are consistent with diminished peripheral circulation? (Select all that apply.)
Answer:
Diminished hair on leg and .Skin cool to touch. Rationale Diminished hair on the legs and skin that is cool
to touch are expectant signs of decreased arterial blood flow.
Question:
3. An older client has just returned to the room following a surgical procedure. Which pain scale should the
nurse use when assessing the client's pain level?
Answer:
Verbal descriptor scale.
Rationale The descriptor scale uses words rather than numbers or pictures to describe pain. This method of
reporting pain is less confusing and less abstract for older adults. The choices provided for rating the
intensity of pain include the following: no pain, mild pain, moderate pain, and severe pain.
Question:
4. How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart
failure?
Answer:
Measure bilateral ankle circumference with a non-stretchable tape measure. Rationale An accurate
assessment of lower extremity edema is required when a client is treated for heart failure. Measuring ankle
circumference is more accurate than other objective measures that can rely on individual interpretation,
such as measuring pitting edema.
Question:
5. The nurse is testing the client's shoulders for range of motion. What should the nurse document to record
normal internal rotation?
Answer:
Range of 90 degrees when the hands are placed at the small of the back.
Rationale To document normal internal rotation of the shoulders, the client should be able to demonstrate a
range of 90 degrees when the hands are placed at the small of the back.
, Question:
6. The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which further
assessment of the area should the nurse perform?
Answer:
Observe the direction of movement.
Rationale Increased peristaltic movements are occasionally seen in very thin clients and may indicate the
presence of intestinal obstruction. In addition to noting the quadrant of origin, the nurse should also note
the direction of the peristaltic flow and report these findings to the healthcare provider.
Question:
7. The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the
right upper quadrant. Which action should the nurse take next?
Answer:
Note the character and frequency of bowel sounds.
Rationale Bowel sounds originate from the air and fluid movement through the stomach and intestines. A
wide range of normal sounds can occur depending on when the last meal was ingested. The nurse should
assess for hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency.
It is not necessary to count the number of bowel sounds per minute and to listen to all four quadrants. It is
necessary to listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.
Question:
8. Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which
additional assessment should the nurse use to verify splenomegaly?
Answer:
Percussion
Rationale When splenomegaly is suspected, percussion of the spleen produces a dull sound and is a safe
method of verifying enlargement.
Question:
9. The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to
visualize?
Answer:
Pharynx
Rationale Depressing the tongue when examining the mouth allows the nurse to visualize the pharynx,
tonsils, and adenoids.
Question:
10. When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound. Which
lung sound should the nurse document?
Answer:
Stridor
Rationale Stridor is an audible monophonic inspiratory crowing sound. Stridor in a client with dyspnea
indicates airway obstruction.
