BSN 246 HESI
BSN 246 HESI Health Assessment V1: NCLEX-Style Practice
Questions with Answers and Rationales
Gradegurus
This exam contains:
❖BSN 246 HESI Health Assessment V1
❖NCLEX-Style Practice Questions with Answers and
Rationales
,Nursing Assessment Quiz – Questions, Answer Choices,
Correct Answers & Rationales
Page 1
1. The nurse is performing a thoracic assessment on a client with
chronic asthma and hyperinflation of the lungs. Which finding
should be expected for this client?
A. Funnel chest
B. Pigeon chest
C. Barrel chest
D. Flail chest
Correct Answer: C. Barrel chest
Rationale: Chronic asthma with hyperinflation leads to an increased anterior-posterior
(AP) diameter of the chest, resulting in a barrel chest appearance. Funnel chest (pectus
excavatum) is a depression of the sternum; pigeon chest (pectus carinatum) is a
protrusion of the sternum; flail chest is paradoxical chest movement from trauma.
,2. The nurse is assessing bowel sounds for a hospitalized client. The
nurse has heard bowel sounds in the right upper quadrant. What
action should the nurse take next?
A. Document the finding as normal and discontinue the assessment
B. Note the character and frequency of bowel sounds
C. Auscultate for 5 minutes in each quadrant
D. Palpate the abdomen to stimulate peristalsis
Correct Answer: B. Note the character and frequency of bowel sounds
Rationale: Once bowel sounds are heard, the nurse should note their character (e.g.,
high-pitched, gurgling) and frequency (e.g., normal, hypoactive, hyperactive). It is not
necessary to auscultate for 5 minutes in each quadrant if sounds are present; that is
done when sounds are absent. Palpation is performed after auscultation.
3. During inspection of a client's mouth and pharynx, the nurse
places a tongue blade on the back of the tongue which causes the
client to gag. After removing the tongue blade, what action should
the nurse take?
A. Notify the healthcare provider immediately
B. Document an intact gag reflex
C. Reassess the client's airway for obstruction
D. Administer an antiemetic as prescribed
Correct Answer: B. Document an intact gag reflex
Rationale: Gagging is a normal response indicating an intact gag reflex (cranial nerves IX
and X). This is a expected finding and should be documented as such. No intervention is
needed.
4. When teaching a client how to perform a monthly breast self-
assessment, the nurse should tell the client that it is most important
, to assess which part of the breast more closely for changes?
A. Lower inner quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
Correct Answer: D. Upper outer quadrant
Rationale: The upper outer quadrant contains the tail of Spence and has the greatest
amount of glandular tissue, making it the most common site for breast cancer. Therefore,
it should be assessed most carefully.
5. The nurse is assessing a postmenopausal client who has a BMI of
32. The client has a chest measurement of 42 inches, waist
measurement of 45 inches, and hip measurement of 50 inches. What
important message should the nurse explain to the client to promote
health promotion?
A. "You need to lose weight to prevent osteoporosis."
B. "Your BMI indicates you are underweight and need to gain weight."
C. "A waist circumference is greater than 35 inches in women puts you at higher risk
for type 2 diabetes and heart disease."
D. "Your hip-to-waist ratio is within normal limits."
Correct Answer: C. "A waist circumference is greater than 35 inches in women puts
you at higher risk for type 2 diabetes and heart disease."
Rationale: A waist circumference >35 inches in women indicates central obesity, which
increases the risk for type 2 diabetes, cardiovascular disease, and metabolic syndrome.
The client's waist is 45 inches, well above the threshold.
6. The nurse performs a physical assessment on an older female
client. Which change from the prior exam may be an indication of
BSN 246 HESI Health Assessment V1: NCLEX-Style Practice
Questions with Answers and Rationales
Gradegurus
This exam contains:
❖BSN 246 HESI Health Assessment V1
❖NCLEX-Style Practice Questions with Answers and
Rationales
,Nursing Assessment Quiz – Questions, Answer Choices,
Correct Answers & Rationales
Page 1
1. The nurse is performing a thoracic assessment on a client with
chronic asthma and hyperinflation of the lungs. Which finding
should be expected for this client?
A. Funnel chest
B. Pigeon chest
C. Barrel chest
D. Flail chest
Correct Answer: C. Barrel chest
Rationale: Chronic asthma with hyperinflation leads to an increased anterior-posterior
(AP) diameter of the chest, resulting in a barrel chest appearance. Funnel chest (pectus
excavatum) is a depression of the sternum; pigeon chest (pectus carinatum) is a
protrusion of the sternum; flail chest is paradoxical chest movement from trauma.
,2. The nurse is assessing bowel sounds for a hospitalized client. The
nurse has heard bowel sounds in the right upper quadrant. What
action should the nurse take next?
A. Document the finding as normal and discontinue the assessment
B. Note the character and frequency of bowel sounds
C. Auscultate for 5 minutes in each quadrant
D. Palpate the abdomen to stimulate peristalsis
Correct Answer: B. Note the character and frequency of bowel sounds
Rationale: Once bowel sounds are heard, the nurse should note their character (e.g.,
high-pitched, gurgling) and frequency (e.g., normal, hypoactive, hyperactive). It is not
necessary to auscultate for 5 minutes in each quadrant if sounds are present; that is
done when sounds are absent. Palpation is performed after auscultation.
3. During inspection of a client's mouth and pharynx, the nurse
places a tongue blade on the back of the tongue which causes the
client to gag. After removing the tongue blade, what action should
the nurse take?
A. Notify the healthcare provider immediately
B. Document an intact gag reflex
C. Reassess the client's airway for obstruction
D. Administer an antiemetic as prescribed
Correct Answer: B. Document an intact gag reflex
Rationale: Gagging is a normal response indicating an intact gag reflex (cranial nerves IX
and X). This is a expected finding and should be documented as such. No intervention is
needed.
4. When teaching a client how to perform a monthly breast self-
assessment, the nurse should tell the client that it is most important
, to assess which part of the breast more closely for changes?
A. Lower inner quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Upper outer quadrant
Correct Answer: D. Upper outer quadrant
Rationale: The upper outer quadrant contains the tail of Spence and has the greatest
amount of glandular tissue, making it the most common site for breast cancer. Therefore,
it should be assessed most carefully.
5. The nurse is assessing a postmenopausal client who has a BMI of
32. The client has a chest measurement of 42 inches, waist
measurement of 45 inches, and hip measurement of 50 inches. What
important message should the nurse explain to the client to promote
health promotion?
A. "You need to lose weight to prevent osteoporosis."
B. "Your BMI indicates you are underweight and need to gain weight."
C. "A waist circumference is greater than 35 inches in women puts you at higher risk
for type 2 diabetes and heart disease."
D. "Your hip-to-waist ratio is within normal limits."
Correct Answer: C. "A waist circumference is greater than 35 inches in women puts
you at higher risk for type 2 diabetes and heart disease."
Rationale: A waist circumference >35 inches in women indicates central obesity, which
increases the risk for type 2 diabetes, cardiovascular disease, and metabolic syndrome.
The client's waist is 45 inches, well above the threshold.
6. The nurse performs a physical assessment on an older female
client. Which change from the prior exam may be an indication of
